5 Design study I: How to create an ambulatory app for patients with BPP 153 BPD [35]. Taken together, there is a clear case for helping these patients to become timely aware of changes in arousal level. When turning to research on alexithymia, results support the hypothesis that alexithymia leads to a decoupling of subjective and physiological arousal when exposed to emotionally negative stimuli [36]. This decoupling of emotion sometimes also addressed as ‘dual-processing’ [37] or ‘lower multisensory integration’ [38] of emotions could possibly even shed some light onto the low levels of response coherence that are observed in some individuals in more generic research on emotional response coherence [39]. This “disconnect” between physical and self-reported responses to emotional stimuli was also found in a study on BPD were patients showed heightened physiological responsiveness yet blunted subjective responses to emotional stimuli [40]. Evidence suggests that BPD patients' propensity for impulsive and self-harming behavior is at least in part due to this failure to adequately process information about emotions [30, 32, 4145]. Vice versa, increased emotional awareness or the ability to identify, describe and fully experience emotions, is positively associated with treatment outcome for BDP [46] and less self-injuring [27]. It reduces the all-ornothing, good-or-bad appraisals of emotional experience often seen in BPD [28, 32]. Regarding general health and well-being, greater emotional awareness is associated with greater self-reported impulse control and stress-regulation, with greater openness to feelings, and more stability in experiencing well-being. It correlates positively with empathy ability, the tendency to seek help for emotional problems, and the actual amount of social support that a person has [22, 34, 47, 48]. There thus exists a veritable need for patients to increase emotional awareness. When reflecting on costs-of-illness, studies on societal costs show a financial burden of BPD of more than €2 billion [in the Netherlands] or almost €17,000 per patient [49, 50]. In a seminar by Lieb et al. [12] published in the Lancet, they present statistics that show that 97% of patients with borderline personality disorder presenting for treatment in the USA receive outpatient care from an average of six therapists during their lifetime; of them 37% also receive day treatment at some point in their lives, and even 72% encounter psychiatric hospitalization. Twenty-four percent receive treatment in a halfway house, and 9–40% of frequent users of inpatient psychiatric services are diagnosed with BPD. As stated above, problematic low emotional awareness is seen in several other mental disorders. Putting matters in a larger perspective, the identified total cost of all brain disorders in Europe is estimated at 447 billion in 2004 and 798 billion in 2010, which outweighs the costs of all the forms of cancers combined [17].
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