3 A meta-analysis on the association between EA and BPP 81 1. Introduction Borderline personality disorder (BPD) is characterized by a pervasive pattern of unstable relations, a distorted self-image, and profound disturbances in the processing, experiencing, and regulation of emotions, frequently resulting in impulsive and self-destructive behavior and severe problems in social and interpersonal functioning [1]. Although BPD and other personality disorders are still represented as categorical diagnoses in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders [2], a growing body of research shows that they are better represented dimensionally ([3-6]. Hence, in this study, we approach borderline personality pathology (BPP) as both a diagnostic category and a dimensional construct encompassing several symptoms and/or traits. Emotional awareness is one of several processes that contribute to the emotion regulatory system [7-9]. Lane and Schwartz [10] describe emotional awareness as a cognitive skill reflecting the ability to recognize and describe emotion in oneself and others. Emotional awareness plays a crucial role in emotional regulation, as it facilitates the application of the crucial skills of modifying, accepting, and tolerating emotions [7, 11-13]. Contemporary clinical theories assume that a lack of emotional awareness accounts for much of the emotional dysregulation in BPP [7, 12, 14-18]. A lack of emotional awareness has been linked to the propensity for impulsive selfdestructive behaviors such as self-harm and suicide [15, 18-20]. When feelings are not adequately identified and described, emotional expression and problem-solving strategies are hampered, resulting in an increase in emotional tension. The occurrence of self-injurious behaviors is seen as a way of expressing and reducing this tension [19, 21-23]. Others have argued, however, that such behaviors are the result of a sudden and almost instantly overwhelming “eruption” of emotion, and researchers have reported on how both emotional hypo-awareness and hyperresponsiveness may be simultaneously present [24, 25]. Evidence-based therapies for BPP, like dialectical behavior therapy, schema-based therapy, and mentalization-based therapy, assume that a lack of emotional awareness is an underlying factor in borderline pathology, as they all share a common focus in helping individuals with BPP to become more aware of their own emotions [20, 26, 27]. Although research on treatment of BPP has predominantly focused on evaluating and comparing the efficacy of the different approaches, other studies have also examined underlying factors [8, 28] and suggest that the ability to identify, describe and fully experience emotions develop over the course of treatment for BPD and are associated with successful treatment outcome [8].
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