Chapter 1 18 act as loud ‘background noise’ that further hampers the ability of emotion identification in patients with BPD [91]. 1.6 (Not) hearing James’ sounding box: The link between interoceptive awareness and emotional awareness As one of the hallmarks of BPD is that patients deeply struggle with emotion regulation, there is no doubt that people with BPP have emotional responses. In fact, many patients with BPP report having ‘too many’ and ‘too strong’ emotions [57]. Still, as it also seems true that they have a lack of emotional awareness due to high levels of alexithymia, reality will be that many of their emotions will play out unnoticed to them. This could – at least in part – explain why in BPD emotions can really get out of proportion – and out of hand [41]. Perception of internal bodily states, or interoceptive awareness, is found to be associated with the subjective experience, awareness, labelling, and understanding of emotional processes [11, 57, 92-95]. Recent findings from neurological studies suggest substantial overlap in systems involved in reflection on somatic experience, subjective emotional experience, and emotion labeling [92-94, 96]. The general notion of interoceptive awareness has been further specified by distinguishing two underlying different, and partially independent, capacities that are included in it: the so-called interoceptive accuracy and interoceptive sensibility [95]. The notion of interoceptive accuracy describes our capacity to identify internal body sensations, while the notion of interoceptive sensibility refers to our capacity to focus on our internal sensations and to take them into consideration from a cognitive point of view. Although still inconclusive, there is some evidence that alexithymics exhibit a normal to excessive activation with respect to the physiological component of emotional arousal [84, 85], but atypical interoceptive awareness [97, 98]. These findings can be interpreted as the result of a combination of normal to heightened interoceptive accuracy and lacking interoceptive sensibility [95]. Although not unequivocal, overall findings from research on BPD show a picture indicative of a lack of interoceptive sensibility: blunted experiences despite heightened physiological responsiveness to emotional stimuli [99-101]. Research findings by Suvak et al. [52] support this notion, showing that BPD patients generally focus less on personal physiological arousal than control participants. Also, Preece et al. [103] come to similar conclusions presenting their ‘attention-appraisal’ model of alexithymia, suggesting a difficulty attending to feelings as one of the main characteristics alexithymia. Had James been studying alexithymia, he would perhaps have contended these patients may fail to notice their ‘sounding box’ [4] producing sound; and when noticing it, failing to hear that the sounds it produces are more than just vibrations but are part of a musical play.
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