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

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.

The association between BPP and NSSI is mediated by alexithymia

N/a.
Each participant will have two appointments: one for filling out questionnaires, one for completing a diagnostic interview on alexithymia

None.

(When entering the study, each participant will be asked to fill out five questionnaires in one session of 60 to 90 minutes. A separate appointment will be scheduled with each individual participant 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].)