1 General Introduction 15 theories on borderline personality pathology (BPP) assume that a lack of emotional awareness accounts for much of the emotional dysregulation in BPP [49]. Although not unique to the disorder, a lack of emotional awareness is reported to occur in a heightened degree [47, 50-55]. Patients with BPD seem to have particularly less focus on the level of emotional arousal, which impedes the process of identifying and labelling of emotions [52]. This hampers emotional expression and effective use of problem-solving strategies, which in turn leads to a persistence and most likely an increase of emotional tension. Self-harm can then result as a means to alleviate this tension [47, 56-59]. Researchers as McMain and Links [38] suggest that “the abilities to identify, describe and fully experience emotions develop over the course of treatment for BPD and are associated with successful treatment outcome” and Farrell and Shaw even go as far as to state that increasing emotional awareness in patients with BPD is no less than “… an important prerequisite to the effective use of cognitive and behavioral interventions” [41]. So according to them, without emotional awareness, (cognitive behavioral) treatment will have little effect at all. 1.4 Alexithymia as a marker of a severe lack of emotional awareness A profound lack of emotional awareness is considered to be the hallmark criterion of a phenomenon called ‘alexithymia’ [60-70]. Official first use of the term was by Sifneos in 1972, who named the condition “alexithymia” from his native Greek meaning “lack of words for emotion” [71, 72]. The term ‘alexithymia’ refers to a personality construct based on a cluster of cognitive characteristics observed initially among patients with classic psychosomatic diseases and later among patients with a broad range of medical and psychiatric disorders [73], for instance psychosomatic disorders [74], PTSD [75], and eating disorders [76-78]. And, as clinicians as Farrell and Shaw and others point out: BPD [41]. The term originated from clinical practice. The term ‘alexithymia’ was first used to define outcomes of a series of clinical observations and interviews of patients with certain somatic disorders. These patients, examined by young psychiatrists Peter Sifneos and John Nemiah, displayed difficulty identifying feelings and distinguishing between feelings and the bodily sensations associated with emotional arousal; difficulty finding words to describe feelings to others; constricted fantasizing and other imaginal activity; and an externally oriented style of thinking [16, 79-81]. Please note: people with alexithymia in general1 do respond to emotional triggers 1 At least ‘type II’, if considering proposed – but disputed – subtypes of alexithymia. For further information on the types of alexithymia, see for instance (at least type II, if considering proposed – but disputed – subtypes of alexithymia. For further information on the types of alexithymia, see for instance 73. Bagby, R.M., et al., An evaluation of
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