Does alexithymia mediate the relationship between non-suicidal self-injury and borderline personality pathology?

Borderline personality disorder (commonly abbreviated as BPD) is a severe
mental health disorder that influences practically all domains of life. The
disorder is characterized by a pervasive pattern of instable relations, a
distorted self-image and profound disturbances in the regulation of emotions.
Borderline personality pathology typically first emerges in early adulthood
(18-25 years of age) and often mildens in later years (40-50 years of age). BPD
is more common in women than men, with a ratio of 70 to 30 percent.
Effectiveness of treatment for BPD related problems and symptomology has
increased over the last decades. However, analyses of outcomes on treatment
measured 2*3 years after termination of treatment suggest that
treatments-as-usual are still marginally effective at best.
A recent study in the Netherlands shows a prevalence rate (five or more
symptoms of the disorder present) of 1.1%; in 3.8 % of the population multiple
BPD symptoms were present (3*4 symptoms), in other words (just) below the
diagnostic threshold. In general, studies show prevalence rates for BPD (i.e.
five or more BPP symptoms present) between 0.5 % and 1.8 % of the total
population.

Marked difficulties in the regulation of affects and impulses are part of the
general diagnostic criteria of all personality disorders , although it is found
to be specifically related to BPP. In fact, it is part of the diagnostic
description of borderline personality disorder (BPD) in the DSM-IV and DSM 5.
Amongst the multitude of expressions of emotion regulation difficulties, one
that stands due to its explicit nature out is the occurrence of deliberate
self-harming behavior or non-suicidal self-injury (NSSI).
Examples of NSSI are cutting, biting, abrading, severing, inserting, burning,
hitting oneself. NSSI is mainly perceived as a maladaptive coping strategy used
by individuals who struggle with a variety of emotion-related difficulties.
It presumably serves several purposes. However, based on review of the
evidence, the most predominant reason for engaging in NSSI is to alleviate or
escape high levels of negative affect or non-specified emotional arousal. NSSI
is a form of dysfunctional emotion regulation that has a severe negative impact
on general wellbeing and health, both psychological and physical.

As the difficulties persons with high levels of BPP encounter with the
regulation of their emotions are manifold, so are the proposed underlying
deficits responsible for them. Of those, one phenomenon gathering increased
attention in recent years is *alexithymia*. Alexithymia, translated from the
Greek language, means *no words for feelings.
Low emotional awareness, as evident by difficulties in recognizing and
identifying emotions, is the key characteristic of alexithymia. Emotional
awareness is one of the processes that contribute to the emotion regulatory
system. It can be described 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. Better 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. There exists a clear association between alexithymia and emotion
regulation difficulties. Studies show a relationship between the lack of
emotional awareness that characterizes alexithymia and the propensity for
impulsive self-destructive behaviors such as NSSI. It is hypothesized that when
feelings are not adequately identified and described, emotional expression and
problem-solving strategies are hampered, which results in an increase in
emotional tension. The occurrence of NSSI is seen as a way of expressing and
reducing this tension. Several scholars and clinicians state 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*.

Although considered a trans-diagnostic factor and thus not unique to BPP,
alexithymia is associated to BPP to an above average degree. A recent
meta-analysis we did confirms the existence of an association between BPP and
alexithymia.

We posit the following hypothesis:(H1) the association between BPP and NSSI is
mediated by alexithymia.
So, in this study, we want to assess whether the association between BPP and
NSSI is mediated by alexithymia. What is known thus far is that BPP is
associated with NSSI as well as with alexithymia, and alexithymia and NSSI also
are associated. It is of significant importance to investigate whether the
association between NSSI and BPP is actually mediated by this deficit in
emotion processing. The current study is designed to advance knowledge on this
topic.

To our knowledge, there are no published empirical studies that report on
whether or not alexithymia mediates the association between BPP and NSSI.
We did find one study in which alexithymia and multiple personality disorders
were assessed in relation to NSSI in a sample of substance depended patients.
Results showed significant effects regarding NSSI increasing with higher
scores on BPP, and significant positive correlations between NSSI and
*difficulties identifying feelings* and *difficulties describing feelings*, two
facets of the alexithymia concept. Unfortunately, no additional analyses
elucidating the interplay between these variables were performed. Also, since
the study was mainly centered on substance dependent patients and they included
several groups for comparison, sample size per analysis was small.

Farrell and Shaw, two acclaimed psychotherapists, stated already some 22 years
ago that psychotherapies for BPP should start by treating alexithymia and
increasing emotional awareness before attempting to treat other problems * such
as NSSI. If our hypothesis proves to be true this would support their
statement.

Primary Objective:
This study aims to identify whether alexithymia is a mediator between BPP and
NSSI.

This study uses a cross-sectional design.
After signing up for participation, participants will be contacted two [2]
times:

The first time they will be asked to fill out five (5) self-report
questionnaires. Participants complete a self-report questionnaire on
alexithymia, on borderline pathology and on non-suicidal self-injury. To adjust
for possible confounding due to other variables, they will also be asked to
fill out a questionnaire on depressive symptomatology and one on dissociative
experiences (see Section 3. Methods). This will yield quantitative data that
will be examined statistically (see Section 5. Statistical Analysis). Filling
out the questionnaires will take between one [1] and one-and-a-half [1,5] hours.

After completing the questionnaires, each participant will be contacted at
another point in time for a semi-structured interview on alexithymia. This
interview will take about 45 to 60 minutes.

Total duration of the study for participants will be one hour and fortyfive
minutes [1h45m] to two-and-a-half hours [2h30m].

The study will take place inside the properties of the mental health institute
the participants come to for treatment as a patient. For each patient, the
study will take place at the same location/building they visit for treatment,
if possible. If not possible, this will be the nearest location of the
institute [for patients] available.
The dates and times for both appointments will be set in advance, upon the
participant*s decision to enter the study. Of course, appointments made are
subject for reschedule if so requested by the participant.

Although this study does not involve *incapacitated subjects*, it does involve
psychiatric patients. Risks to which they are exposed are deemed small to
negligible. Participation in this study is only after informed consent.
Although the assessed variables can be experienced as discomforting topics for
participants * especially concerning self-harming behaviour - these topics are
addressed through questionnaires only and thus assessed in a discreet and
private manner.

After signing up for participation, participants will be contacted two [2]
times:

The first time they will be asked to fill out five (5) self-report
questionnaires. Participants complete a self-report questionnaire on
alexithymia, on borderline pathology and on non-suicidal self-injury. To adjust
for possible confounding due to other variables, they will also be asked to
fill out a questionnaire on depressive symptomatology and one on dissociative
experiences (see Section 3. Methods). This will yield quantitative data that
will be examined statistically (see Section 5. Statistical Analysis). Filling
out the questionnaires will take between one [1] and one-and-a-half [1,5] hours.

After completing the questionnaires, each participant will be contacted at
another point in time for a semi-structured interview on alexithymia. This
interview will take about 45 to 60 minutes.

Total duration of the study for participants will be one hour and fortyfive
minutes [1h45m] to two-and-a-half hours [2h30m].

The study will take place inside the properties of the mental health institute
the participants come to for treatment as a patient. For each patient, the
study will take place at the same location/building they visit for treatment,
if possible. If not possible, this will be the nearest location of the
institute [for patients] available.
The dates and times for both appointments will be set in advance, upon the
participant*s decision to enter the study. Of course, appointments made are
subject for reschedule if so requested by the participant.

There is no obvious direct benefit in participating for individual
participants, although individual results can be provided upon request and may
than be used for personal insight, for example in treatment.
Since all variables involved in this study bear significant impact on the
effect and outcome of treatment and thereby the wellbeing of this target group,
the potential group benefit is considered substantial. Results could eventually
lead to significant improvements in treatment given to this group.

As the variables of interest are relatively frequent and of clinical
significance in the patient group * in contrast to the general population where
they are rare and clinically insignificant (in other words qualitatively
different), we deem the selection and involvement of patients in treatment for
their personality problems necessary and appropriate. For example, (direct)
NSSI occurs in about 4% of the non-clinical population, where it occurs in
about 20% of the adult psychiatric population * and even significant higher
rates apply for specific patient groups such as those with an antisocial or
borderline personality disorder. Next, many studies found higher prevalence
rates of alexithymia in psychiatric disorders. prevalence rates in the normal
population float around 5 * 17%, averaging somewhere on 13%; prevalence rates
in psychiatric populations around 17 * 27%.