4 Exploring the mediating role of alexithymia in BPP 117 With regard to an explanatory model for the relationship between BPP and dissociative experiences (DIS), similar logic can be applied when considering alexithymia as a potential mediator. Next to an association to BPP [72], outcomes of clinical studies show a strong association between DIS and alexithymia [26]. Dissociation is generally understood as a ‘regulatory response to fear or other extreme emotion’ [73]. It is said to modulate levels of extreme affect [26]. Patients ‘tune out’ because of a psychological overload: when their emotional arousal (greatly) exceeds their ‘window of tolerance’; a state of hyperarousal is followed by reactionary hypo-arousal and ‘freezing’ [74]. The exact linking mechanisms between alexithymia and dissociation are still under debate. However, alexithymia could help to explain why patients with higher BPP more easily end up in experiencing extreme levels of affect and dissociate: In situations that are stressful, due to higher levels of alexithymia these patients do not adequately identify and act upon their increasing levels of emotional arousal. This could then result in stress levels exceeding the window of tolerance and consequent dissociation. When they become more aware of and attuned to their feelings, they may need to rely less on dissociation as a coping mechanism [25, 26, 75]. Probably, the assumption of alexithymia as a mediator has been most pronounced in the theoretical explanatory models on the interplay between BPP and SIB. The association between alexithymia and SIB been confirmed in multiple studies [70, 76]. SIB is known to serve as a means to reduce high levels of arousal and diffuse negative affect [18, 51, 77-81]. SIB may concern any deliberate or intentional behavior that has clear, definite or probable negative effects on the self or on the self's projects [82, 83]. Two broad categories of SIB can be distinguished: direct and indirect SIB (although the two are found to be “remarkably similar” in essence [82, 84-86]). Direct SIB is most often addressed as ‘non-suicidal self-injury’ (NSSI) [87, 88]. Indirect SIB concerns behaviors that are clearly damaging to the self but do not involve immediate deliberate damage to body tissue [82]. Examples of the latter are binge drinking or binge eating, deliberate self-deprivation of food, use of illicit drugs, engaging in dangerous sexual acts (‘sex as self-injury’ or SASI [84]), excessive speeding in traffic, picking fights, et cetera [85]. Several authors content that in patients with BPD high levels of alexithymia are present and as such, constitute a key factor to engaging in SIB: because individuals with higher levels of BPP have difficulties in identifying and describing feelings [32, 89-91], they rather express and regulate negative emotions with ‘actions instead of words’ [28, 92-94]. Thus, alexithymia is presumed to serve a mediating role between BPP and different types of self-harming behavior.
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