4 Exploring the mediating role of alexithymia in BPP 135 appliance of mediational analyses in social sciences [128], a limitation it brings is that any form of causality can only be assumed on account of theory or previous research. In our design we assumed BPP ‘precedes’ alexithymia, based on research that shows that genetic factors have a substantial role in the development of BPP [44, 45], whereas contemporary research indicates that alexithymia may primarily be a result of (traumatic) experiences in early childhood [25]. Still, more research is needed, as alexithymia for example also has been regarded a transdiagnostic factor in recent theory and research, underlying multiple forms of psychopathology, of which one is BPP [3, 22]. Replication in a longitudinal, preferably (quasi)experimental design is needed to confirm whether any of the effects, or the lack thereof, are solid and substantial. Second, our patient sample had a high average alexithymia score, well above (nonpatient) samples from other studies [126, 129]. Although alexithymia scores were normally distributed in the sample, it still can have negatively affected validity of measures in some way. Although we measured alexithymia not only by self-report but also via a structured interview, we did use self-report measures for the other variables in this study. As highly alexithymic patients have limited emotional awareness and limited introspective abilities, it could be that they were not fully capable of indicating their levels of other concepts, for example depressive symptoms or dissociative experiences. The high level of alexithymia in our sample is likely attributable to ‘natural’ sampling bias: information on the leaflets used to recruit participants informed the reader about the nature of the study that was about gathering information and expanding knowledge ‘on the ability to recognize emotions’ and its relationship to different forms of self-injurious behaviors. It is not unlikely that this topic predominantly appealed to persons who encounter such difficulties themselves, which can have been decisive factor to participate in this study. Indeed, many of the participants said when entering the study, they did so because they experienced difficulties in identifying and describing emotions or had been told so by their therapist. Still, the mean scores of both TSIA and TAS-20 were quite comparable to those of a study of Belgium patients in a study of Meganck, Inslegers [118]. 6. Conclusion The results of this explorative study confirm positive relationships of BPP with alexithymia, depressive symptoms, dissociative experiences and self-injurious behaviours in a clinical population. They also confirm associations of alexithymia with depressive symptoms and dissociative experiences. They however did not confirm existence of an association between alexithymia and self-injurious behaviours.
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