4 Exploring the mediating role of alexithymia in BPP 115 1. Introduction Borderline personality pathology (BPP) represents the pathology of borderline personality disorder (BPD) on a spectrum [1]. There is ample evidence of high cooccurrence of BPP with many other forms of psychopathology [2]. Patients with high levels of BPP (i.e.: BPD) often feel depressed, experience dissociative symptoms and engage in ‘dysregulated behaviors’ [3], i.e., direct and indirect self-injurious behaviors (SIB) that are detrimental to overall health and wellbeing [4]. There is a lively debate regarding the question of why persons with high levels of BPP have these affective and behavioral problems [5-21]. One phenomenon that has been found to be related to BPP [22], depressive symptoms [23, 24], dissociative experiences [25, 26], and SIB [3, 27-31], is alexithymia [32]. Alexithymia is a deficit in emotion information processing [33-35]. It consists of four facets: difficulty identifying feelings, difficulty describing feelings, externally oriented thinking and reduced fantasy and other imaginal processes [36, 37]. The first two facets collectively represent an emotional awareness component, nowadays considered to be the main characteristic of alexithymia [33, 35, 37-41]. There is accumulating evidence that supports the view that alexithymia is a “transmission mechanism between negative attachment experiences and impaired interpersonal functioning which, in turn, has been linked to SIB” [42, 43]. In a recent study, Edwards, Rose [43] provided further evidence that alexithymia partially mediates the association of childhood adversity (e.g., abuse, neglect, or disruptions in attachment, often occurring within the context of a relationship with a parent or caregiver) to several aspects of emotion dysregulation. Although genetics appears to play a key role in BPP [44-46], childhood adversity is assumed to also be a factor contributing to development of BPP [43, 46]. In fact, a meta-analysis reported that individuals with BPD are 13.91 times more likely to report experiences of childhood adversity than healthy controls and 3.15 times more likely than individuals with other psychiatric disorders [47]. As contemporary research indicates that alexithymia may also primarily be a result of (traumatic) experiences in early childhood [25], alexithymia could be an interrelated element that (partially) explains the relationship of BPP with these other clinical variables. An explanatory model proposed for this study would be that higher BPP, stemming from (primarily) genetics and (additional) childhood adversities, results in higher levels of alexithymia. If emotion is then activated, but the person remains unaware of that, it is not possible to consciously and intentionally use emotion regulation strategies [41]. Partially dependent of further idiosyncratic variables per patient, this then is expected to lead to various forms of psychopathology, such as aforementioned depressive symptoms, dissociation and/or SIB. As Fink, Anestis [48] put it: “… faced with negative affect, many individuals are able to recognize and process their
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