Chapter 4 116 emotions adaptively. However, if people are not able to identify or describe their emotions, […] this confusing affective experience may be quite upsetting and could lead to […] a tendency to act rashly when they experience any type of negative affect.” A scope of the literature shows there is a need for further development and empirical validation of such explanatory models. As of now, existing work on alexithymia, BPP and related clinical variables is still often based on bivariate associations [42, 49, 50], although there is an increasing number of studies that explore moderation (e.g. [3, 51-54]). Still, there seems to be no study directly examining the possibility of alexithymia being a mediator in the interplay between BPP and other variables. Hence, the current study explores whether alexithymia mediates the associations of BPP with respectively depressive symptoms (DEP), dissociative experiences (DIS), and SIB. Within the spectrum of personality disorders, BPP represents a discrete form of psychopathology. Although the most recent edition of the DSM still features categorical diagnoses [55], a growing body of research shows that personality disorders are better represented dimensionally, placing individuals on a spectrum (or spectra) of traits [56-61]. There is strong empirical support to consider BPP as a single latent factor that underlies all nine BPD criteria [44, 62-64] (although concurrent evidence suggests that this single factor simultaneously consists of three homogeneous components [44]). In reaction, when citing other studies, we will mention ‘patients with high levels of BPP’ where these patients were most likely described as ‘patients with BPD’ in the original paper. Recent studies show that even low levels of BPP, as little as one feature of BPD being present, is clinically relevant as it is associated with psychiatric comorbidity and functional disability [57, 58, 61, 62, 65, 66]. BPP is common among patients in mental health care. In the Dutch general population, more than 25 percent meets 1 to 2 clinical symptoms of BPP [61]. BPP and alexithymia both have strong associations with depressive symptoms (DEP) [67-70]. From a clinical theoretical perspective, it is easy to comprehend how alexithymia would mediate the relationship between BPP and DEP: as high levels of BPP leads to high levels of alexithymia, patients with high BPP are expected to remain unaware of minor but significant internal and external stressors. As a result of their difficulties in identifying and describing their feelings, they will not act upon these stressors, resulting in a plateau of stress. With accumulating stressful events this could then lead to a buildup of emotional tension, most likely experienced by the alexithymic individual as rather diffuse feelings of negative affect and (cognitive and behavioral) symptoms of depression [71].
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