Alexithymia in adolescents with borderline personality disorder

Leveling Up Dialectical Behavior Therapy for Autistic Individuals with Emotion Dysregulation: Clinical and Personal Insights

Autistic people may experience high emotion and sensory sensitivities and a slow return to baseline emotional state. Dialectical behavior therapy (DBT) was developed to address reactivity, impulsivity, and mood dysregulation in individuals with mood and personality disorders. DBT may be therapeutically beneficial to autistic individuals struggling with these or similar emotional and sensory challenges. This article is a synthesis of the first author's experiences of DBT as an autistic person and professional insights from all authors. We provide an overview of the development of DBT, its foundational components, and adaptations. Using this basis, the first author describes the benefits DBT has had, the modifications that have helped him, and how those modifications may enhance DBT for autistic people. Modifications include visuals, graphics, and a gaming format that target the client's personal interests. The essence of these alterations is to transform life skills and DBT skills into something meaningful and functional. Receptivity of the therapist to the modifications and neurodivergent problem solving may be foundational to therapeutic success. Client-initiated contributions in collaborative therapy may improve autistic participants' understanding, validation, and adherence with DBT. The authors suggest expanding work on DBT modifications for autism in the areas of daily self-monitoring, assessing for preferred visual and gaming formats, and utilizing personal interests.

[Alexithymia and self-harm in people with borderline personality disorder]

OBJECTIVE

To estimate the prevalence of alexithymia and self-harm in patients with borderline personality disorder (BPD). To assess the role of alexithymia in the emergence of self-harm in patients with BPD.

MATERIAL AND METHODS

We studied 104 patients (85 women, 19 men aged 21 to 25 years (64.4%)), including 54 patients with and 50 patients without BPD. Most of them had incomplete higher education (55%). We used the Russian version of the 20-item Toronto Alexithymia Scale (TAS-20) to reveal alexithymia and SCID-II to diagnose BPD. The presence of self-harm behavior was confirmed by the subjects' anamnesis data.

RESULTS

The prevalence of alexithymia in patients with BPD was 83.3%, in the control group it was 52% (p=0.001). The prevalence of self-aggression was 70.3% (n=38) in patients with BPD, and 12% (n=6) in people without BPD. Self-harm among persons with alexithymia was noted in 62.5% (n=45). During the analysis, a connection between auto-aggression and alexithymia was found at the level of a statistical trend (p=0.051).

CONCLUSION

Alexithymia and self-harm are more common in patients with BPD than in healthy people. This type of emotional dysregulation mediates self-harm in patients with BPD.

The relationship between alexithymia, emotion regulation, and sleep problems in school-aged children: A multicentric study

OBJECTIVES

Alexithymia, mood dysregulation, and sleep quality have complicated effects on children's development. The current study aimed to investigate the relationship between alexithymia, emotion regulation, psychiatric problems, and sleep problems among Egyptian school-aged children.

METHODS

A total of 564 Egyptian children, aged 6 to 14, were divided into two groups based on their total Children's Sleep Habits Questionnaire abbreviated score: group 1 (N = 300) with sleep problems and group 2 (N = 264) with non-sleep problems. Their parents completed the Strengths and Difficulties Questionnaire (SDQ) and subjectively assessed the children's emotions using the Children's Alexithymia Measure (CAM) and the Clinical Evaluation of Emotional Regulation-9 (CEER-9).

RESULTS

Males were more proportional in the sleep problems group than others. The sleep problem group was significantly younger and had a longer daily sleep duration than the non-sleep problem group. Alexithymia and emotion dysregulation had the highest mean in the sleep problem group. Furthermore, alexithymia, emotion dysregulation, emotion difficulty, conduct, and prosocial problems were the most significant contributing factors and risk factors for sleep problems in children.

CONCLUSION

Sleep problems in children were associated with younger male children with lengthy daily sleep duration and emotional, behavioural, and prosocial difficulties. Furthermore, alexithymia and emotion dysregulation are significant contributors and risk factors for sleep problems in school-aged children.

On Experiential Loneliness

Presumably, everyone has, at some point in their lives, felt lonely. Loneliness is, in that particular sense, omnipresent. What it feels like to be lonely can, however, vary significantly. Loneliness is far from being a homogeneous phenomenon. Different kinds of loneliness need to be distinguished, considering its causes, contexts, a person's capacities to cope with it, and many other factors. This paper introduces the notion of a specific kind of loneliness: experiential loneliness. Experiential loneliness, it will be argued, consists in particular ways of experiencing the world, oneself, and others. Although feelings of being lonely in one way or another can emanate from one's experience of the world being structured in a particular manner, such kinds of loneliness need not-at least, not always and the whole time-lead to emotional feelings that are concerned with one's loneliness or the lack of meaningful social relationship. Loneliness can give rise to quite different emotional feelings that sometimes even cover up their provenience from underlying experiential loneliness. The notion of experiential loneliness, it is suggested, helps to tie back certain styles of thinking, desires, feelings, and behaviors to contexts of loneliness. Moreover, it will be argued that the notion can also elucidate the development of feelings of being lonely in contexts in which others are not only around but also available. To develop and enrich the notion of experiential loneliness as well as to exemplify its usefulness, a closer look will be taken at the case of borderline personality disorder, a condition in which sufferers are often plagued by loneliness.

Impaired complex theory of mind and low emotional self-awareness in outpatients with borderline personality disorder compared to healthy controls: A cross-sectional study

Studies on the theory of mind (TOM) and alexithymia in borderline personality disorder (BPD) have yielded inconsistent results. Also, the relationship between TOM abilities and alexithymia facets as two domains of social cognition has not been studied in BPD. This study aimed to fill this gap. Participants were 50 outpatients with BPD and 50 age and gender-matched healthy controls. Assessments performed using Reading the Mind in Eyes Task (RMET), Toronto Alexithymia Scale (TAS-20), Faux Pas Task (FPT), and Digit Span subtest of Wechsler Adult Intelligence Scale. Results showed that BPD patients scored lower on overall FPT (p < .001) and its cognitive (p < .001) and affective TOM (p < .001) subtests but were comparable with healthy controls in emotion recognition ability assessed by RMET (p = .241). The BPD group also scored significantly lower in overall alexithymia (p < .001) and subscales of difficulty identifying feelings (DIF; p < .001) and difficulty describing emotions (DDF; p = .001). However, they performed similarly to the healthy control group in externally oriented thinking (EOT; p = .164). Correlation analysis revealed a significant negative correlation between EOT and RMET in the BPD group (r = -0.33, p < .05). No association, however, was found between FPT and RMET. This study suggests that BPD patients are impaired in the complex TOM abilities and have lower self-awareness of emotions, but their recognition of others' emotions is intact. Also, the results demonstrate that a heightened level of EOT is associated with difficulties in facial emotion recognition in BPD patients.

The Role of Alexithymia in Social Withdrawal during Adolescence: A Case-Control Study

Although social withdrawal is becoming increasingly common among adolescents, there is still no consensus on its definition from the diagnostic and psychopathological standpoints. So far, research has focused mainly on social withdrawal as a symptom of specific diagnostic categories, such as depression, social phobia, or anxiety disorders, or in the setting of dependence or personality disorders. Few studies have dealt with social withdrawal in terms of its syndromic significance, also considering aspects of emotion control, such as alexithymia. The present case-control study aimed to further investigate the issue of social withdrawal, and try to clarify the part played by alexithymia in a sample of Italian adolescents diagnosed with psychological disorders (n = 80; Average Age_g = 15.2 years, SD = 1.49). Our patients with social withdrawal (cases) scored significantly higher than those without this type of behavior (controls) in every domain of alexithymia investigated, using the Toronto Alexithymia Scale (TAS-20) and with the scales in the Youth Self-Report (YSR) regarding internalizing problems, anxiety-depression, social problems, and total problems. Internalizing problems and total levels of alexithymia also emerged as predictors of social withdrawal. These variables may therefore precede and predispose adolescents to social withdrawal, while social problems may develop as a consequence of the latter.

Interpersonal Relatedness and Non-suicidal Self-Injurious Behaviors in Female Adolescents With Borderline Personality Disorder

Background: Psychopathological models of adolescent borderline personality disorder (BPD) suggest that non-suicidal self-injuring (NSSI)-a particularly frequent symptom in girls-may constitute a way of coping with distress resulting from interpersonal concerns they typically experience as a developmental psychopathological feature. Objectives: Our objective was to investigate the relationship in BPD female adolescents between NSSI and the Sidney Blatt two-polarities model of personality development, which focuses on the psychological processes of interpersonal relatedness and self-definition. Methods: The study was conducted within the European Research Network on Borderline Personality Disorder in Adolescence, using the Depressive Experience Questionnaire (DEQ). Results: BPD patients (n = 59; mean age = 16.6 ± 1.3) scored significantly higher than healthy controls on the two DEQ sub-factors assessing the more immature forms of Interpersonal Relatedness (Neediness) and Self-definition (Self-criticism) and significantly lower on the more mature form of Self-definition (Efficacy). BPD adolescents with NSSI showed significantly higher scores on both mature and immature forms of Interpersonal Relatedness (Neediness and Connectedness) compared to BPD adolescents without NSSI. A logistic regression analysis showed that the subfactor Neediness of the DEQ was the only significant predictor of the presence of NSSI among BPD adolescents. Conclusions: The preliminary results of this study suggests that NSSI in adolescents with BPD is developmentally linked to high developmental concerns in the domain of interpersonal relatedness, which may be taken into consideration in clinical practice. More studies are necessary to better understand the relationships between NSSI and developmental psychopathology in borderline adolescents.

Evidence for Altered Neural Processing in Patients With Borderline Personality Disorder

Abstract. Borderline personality disorder (BPD) is characterized by difficulties in emotion regulation, self-identity disturbances, self-injurious behavior, and reduced inhibitory control. Event-related potential (ERP) studies have sought to reveal the neural correlates of cognitive distortions and behavioral alterations in BPD. The article presents an overview of the existing ERP literature pertaining to BPD and discusses whether any one of the electrophysiological findings could serve as a reliable and specific marker for BPD. In short, ERP studies investigating P300 tentatively suggest impaired inhibitory control. Moreover, reduced error- and feedback-related processing and impaired response inhibition seem to be associated with impulsivity and risk-taking behavior in BPD patients. However, these findings are not specific for BPD. Regarding emotional and self-referential information processing, individuals with BPD display heightened vigilance toward social threat impacting their cognitive performance in various social-cognitive tasks demonstrating alterations of early negative and late positive potentials. These multifaceted electrophysiological alterations may be attributed to dysfunctional activity and connectivity of frontal brain regions and the limbic system.

Empathy, Alexithymia, and Theory of Mind in Borderline Personality Disorder

The purpose of this research was to determine the differences in empathy, alexithymia features, and theory of mind between healthy controls and patients with borderline personality disorder (BPD). Thirty-five patients with BPD and 35 healthy controls were included in the study. To measure the clinical variables, the Empathy Quotient (EQ), Reading the Mind in the Eyes Test (RMET), Toronto Alexithymia Scale (TAS-20), Barratt Impulsivity Scale-11 (BIS-11), and Beck Depression Inventory (BDI) were applied. We found that the BPD group had significantly worse total RMET and neutral RMET scores than the control group. There were no differences in the EQ scores between the BPD and control groups. The patients with BPD were more alexithymic than the controls, and alexithymia and depression scores predicted BPD status. Patients with BPD who have difficulty identifying their own emotions tend to display deficits in perceptions of facial emotions, which, in turn, may lead to misperceptions of social signals and thus contribute to excessive emotional intensity and tension in social situations. The study results reveal that alexithymia and depression are important variables in predicting BPD traits.

Examining the Relationship Between Executive Functions and Mentalizing Abilities of Patients With Borderline Personality Disorder

Patients with borderline personality disorder (BPD) experience interpersonal dysfunctions; therefore, it is important to understand their social functioning and the confounding factors. We aimed to investigate the mentalizing abilities and executive functioning (EF) of BPD patients and healthy subjects and to determine the relative importance of BPD diagnosis and EF in predicting mentalizing abilities while controlling for general IQ and comorbid symptom severity. Self-oriented mentalizing (operationalized as emotional self-awareness/alexithymia), other-oriented mentalizing [defined as theory of mind (ToM)], and several EF domains were examined in 18 patients with BPD and 18 healthy individuals. Decoding and reasoning subprocesses of ToM were assessed by standard tasks (Reading the Mind in the Eyes Test and Faux Pas Test, respectively). Relative to controls, BPD patients exhibited significant impairments in emotional self-awareness and ToM reasoning; however, their ToM decoding did not differ. Multivariate regression analyses revealed that comorbid psychiatric symptoms were negative predictors of alexithymia and ToM decoding. Remarkably, the diagnosis of BPD was a positive predictor of ToM decoding but negatively influenced reasoning. Moreover, EF had no impact on alexithymia, while better IQ, and EF predicted superior ToM reasoning. Despite the small sample size, our results provide evidence that there is a dissociation between mental state decoding and reasoning in BPD. Comorbid psychiatric symptoms could be considered as significant negative confounds of self-awareness and ToM decoding in BPD patients. Conversely, the impairment of ToM reasoning was closely related to the diagnosis of BPD itself but not to the severity of the psychopathology.

Attachment to Parents and Peers and Adolescent Mental Health: The Mediating Role of Alexithymia

The current research aims to study the mediating role of alexithymia on the relationship between attachment to parents and peers and mental health problems in a sample of 242 non-referred adolescents. Participants completed the Inventory of Parent and Peer Attachment, the Toronto Alexithymia Scale, and the Symptom Check List-90-R. Mediation analysis shows that alexithymia fully mediates the relations between attachment to peers and mental health problems in both adolescent males and females. Findings suggest the importance to identify promptly vulnerabilities and risks in order to create prevention and intervention programs aimed to foster positive attachment experiences and to support emotional regulation.

Explicit and Implicit Responses of Seeing Own vs. Others' Emotions: An Electromyographic Study on the Neurophysiological and Cognitive Basis of the Self-Mirroring Technique

Facial mimicry is described by embodied cognition theories as a human mirror system-based neural mechanism underpinning emotion recognition. This could play a critical role in the Self-Mirroring Technique (SMT), a method used in psychotherapy to foster patients’ emotion recognition by showing them a video of their own face recorded during an emotionally salient moment. However, dissociation in facial mimicry during the perception of own and others’ emotions has not been investigated so far. In the present study, we measured electromyographic (EMG) activity from three facial muscles, namely, the zygomaticus major (ZM), the corrugator supercilii (CS), and the levator labii superioris (LLS) while participants were presented with video clips depicting their own face or other unknown faces expressing anger, happiness, sadness, disgust, fear, or a neutral emotion. The results showed that processing self vs. other expressions differently modulated emotion perception at the explicit and implicit muscular levels. Participants were significantly less accurate in recognizing their own vs. others’ neutral expressions and rated fearful, disgusted, and neutral expressions as more arousing in the self condition than in the other condition. Even facial EMG evidenced different activations for self vs. other facial expressions. Increased activation of the ZM muscle was found in the self condition compared to the other condition for anger and disgust. Activation of the CS muscle was lower for self than for others’ expressions during processing a happy, sad, fearful, or neutral emotion. Finally, the LLS muscle showed increased activation in the self condition compared to the other condition for sad and fearful expressions but increased activation in the other condition compared to the self condition for happy and neutral expressions. Taken together, our complex pattern of results suggests a dissociation at both the explicit and implicit levels in emotional processing of self vs. other emotions that, in the light of the Emotion in Context view, suggests that STM effectiveness is primarily due to a contextual–interpretative process that occurs before that facial mimicry takes place.

Altered interoception in patients with borderline personality disorder: a study using heartbeat-evoked potentials

BACKGROUND

Patients with borderline personality disorder (BPD) experience difficulties in emotional awareness (alexithymia), and often develop dissociative symptoms, which may reflect broader deficits in interoceptive awareness. Whether this is associated with alterations in cortical processing of interoception is currently unknown.

METHODS

We utilized an electrophysiological marker of interoception, i.e. heartbeat-evoked potentials (HEP), and examined its relationship with electrocardiographic correlates of autonomic nervous system (ANS) functioning (heart rate variability), and with self-report measures of alexithymia, dissociation and borderline symptom severity in patients with BPD.

RESULTS

Individuals with BPD had higher HEP amplitudes over frontal electrodes compared to healthy controls. Sympathetic ANS activity was greater in BPD patients than in controls. Across groups, HEP amplitudes were associated with parasympathetic activity over central electrodes and correlated with alexithymia over frontal electrodes.

CONCLUSIONS

These findings support the idea that difficulties in emotional awareness in BPD are reflected in altered frontal electrophysiological markers of interception. Therefore, emotional awareness can be understood as failures of modulation between interoceptive and exteroceptive attention. Future research may aim to investigate whether altered interoception and its electrophysiological correlates are malleable by therapeutic intervention.

Alexithymia predicts maladaptive but not adaptive emotion regulation strategies in adolescent girls with anorexia nervosa or depression

BACKGROUND

Among adolescent girls, anorexia nervosa (AN) and major depression (MD) are common and often comorbid mental health problems. Both disorders are characterised by difficulties in recognising and verbalising (alexithymia) as well as regulating one's emotions, but research in adolescent patients is scarce and little is known about the relation between alexithymia and difficulties in emotion regulation. The aims of this study were to investigate alexithymia and emotion regulation skills in adolescents with AN, adolescents with MD, and healthy adolescents, and to determine whether alexithymia functions as a predictor for emotion regulation skills.

METHODS

Emotion regulation strategies, alexithymia, and depressive symptoms were assessed by questionnaire measures in 12-18 year old girls with AN (n = 26), girls with MD (n = 25), and healthy girls (n = 35). Groups were compared with respect to the these variables and multiple regression analyses were calculated separately for adaptive and maladaptive emotion regulation strategies in order to examine if alexithymia predicted emotion regulation over and above age and depressive symptoms.

RESULTS

Girls with AN or MD both reported using adaptive emotion regulation strategies less frequently and maladaptive emotion regulation skills more frequently as well as higher levels of alexithymia compared to healthy girls. Alexithymia positively predicted maladaptive emotion regulation strategies, while depressive symptoms negatively predicted adaptive emotion regulation strategies.

CONCLUSIONS

The results suggest that different mechanisms may underlie the lack of adaptive and the surplus of maladaptive emotion regulation strategies in adolescent psychiatric patients.

Facial emotion recognition deficits and alexithymia in borderline, narcissistic, and histrionic personality disorders

Previous studies that aimed to support emotion recognition deficits and alexithymia in B cluster personality disorders have mainly focused on borderline personality disorder (BPD), and resulted in mixed findings. In our study we examine emotion recognition and alexithymia in patients with histrionic (HPD), narcissistic (NPD) and borderline (BPD) personality disorders compared to each other and healthy controls. Furthermore, the possibility is investigated that it is not the type of PD but the severity of psychopathology which predicts the severity of emotion recognition deficits and alexithymia. Patients with HPD, NPD, BPD and healthy controls (N = 20 for each group) were examined by using the Ekman 60 Faces Test (FEEST) and the Toronto Alexithymia Scale (TAS-20). To measure the extent and severity of psychopathology, the Symptom-Checklist-90 Revised (SCL-90-R) was used. Patient groups performed significantly worse compared to healthy controls on the Ekman test and TAS-20, while we found no significant differences among patient groups in emotion recognition and alexithymia. Furthermore, higher scores on the SCL-90-R predicted poorer emotion recognition performance and higher alexithymic features. The empirical data supports the conclusion that the severity of psychopathology plays an important role in predicting emotion recognition deficits and alexithymia in borderline, narcissistic, and histrionic personality disorders.

Assessing advanced theory of mind and alexithymia in patients suffering from enduring borderline personality disorder

Findings on the theory of mind (ToM) abilities in borderline personality disorder (BPD) have been inconsistent. Surprisingly, no studies have focused on the complex aspects of ToM while simultaneously measuring alexithymia as well as comorbid depressive and anxiety symptoms, therefore, our study aimed to fill this gap. 30 female patients with BPD and 38 healthy controls (HCs) completed the Faux Pas Test (FPT) and the Toronto Alexithymia Scale-20 (TAS-20). The clinical and intellectual assessment comprised of the Structured Clinical Interview for DSM-IV-TR Axis II Disorders (SCID-II), the Borderline Personality Inventory (BPI), the State-Trait Anxiety Inventory (STAI), the Center for Epidemiologic Studies Depression Scale-Revised (CESD-R), and the Raven's Progressive Matrices (RPM). Women with BPD scored significantly worse than HCs on overall ToM abilities. After controlling for the intelligence level, depressive symptoms, and state and trait anxiety, both groups presented a similar overall level of alexithymia. No correlation between the FPT and TAS-20 scores was found, suggesting that both constructs might be unrelated in BPD. Because ToM dysfunctions seem not to result from comorbid clinical symptoms, trait anxiety, or intellectual abilities, our study results suggest that ToM deficits might be considered a core feature of BPD.

Headache and Alexithymia in Children and Adolescents: What Is the Connection?

Background: Headache is one of the most common complaints in children and adolescents and comorbidity rates are very high and the major associated diseases are depression, anxiety, atopic disorders, sleep, and behavioral disorders. In recent years, it has been highlighted that difficulties regulating emotions such as alexithymia have also been associated with diagnosis of somatization. Methods: We carried out a mini review analyzing the relation between alexithymia and primary headache (e.g., migraine and tension type headache) in children and adolescents by synthesizing the relevant studies in the literature on PubMed, PsycINFO, and Google Scholar. Search terms were "alexithymia" combined with the "primary headache," "migraine," "tension type headache," "children," and "adolescents." Results: All analyzed studies found higher levels of alexithymia in children and adolescents with headache than control groups but there are different opinions about the relationship between headache and alexithymia. For example, some studies suggest that the association between headache and alexithymia in children may be due to an incomplete development of emotive competency or a general immature cognitive development, instead other studies found a correlation between headache symptoms, insecure attachment, and alexithymia. There seems to be also differences between children with migraine compared to those with tension type headache (TTH). Conclusion: There are some studies on adults suffering from headache or migraine and alexithymia, but there is only a moderate amount of research on pediatric age with different opinions and theories about this relationship. Further studies on children and adolescents are necessary to effectively understand this relationship and to help children to reduce headache and improve emotional consciousness.

Reduced white matter integrity in borderline personality disorder: A diffusion tensor imaging study

BACKGROUND

Borderline personality disorder (BPD) has a pervasive pattern of instability in interpersonal relationships, self-image, and emotions. BPD may be linked to an abnormal brain anatomy, but little is known about possible impairments of the white matter microstructure in BPD or their relationship with impulsivity or risky behaviors. The aims of the present study were to explore the relationship between BPD and diffusion tensor imaging (DTI) parameters and psychological tests.

METHODS

We evaluated 35 un-medicated BPD patients in a medication-free state and 50 healthy controls (HCs). We performed DTI tractography in BPD patients and HCs. The Childhood Trauma Questionnaire (CTQ), Profile of Mood State (POMS), State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI), Social Adaptation Self-Evaluation Scale (SASS), and Depression and Anxiety Cognition Scale (DACS) were administered to BPD patients and HCs.

RESULTS

A tract-based spatial statistics (TBSS) revealed that the BPD group had three clusters with a significantly lower axial diffusivity (AD) than the HC group: one located mainly in the cingulum and the other mainly in the inferior front-occipital fasciculus and inferior longitudinal fasciculus. Regarding the AD values, one cluster correlated negatively and significantly with POMS (Depression) and it was located in the cingulum, while another cluster correlated positively and significantly with DACS (Future Denial) and it was located in the inferior front-occipital fasciculus (IFOF).

LIMITATIONS

The small sample size of this study prevents us from forming any definitive conclusions, meaning that more studies are needed to confirm our findings. We are unable to generalize our findings to include other ethnic groups.

CONCLUSIONS

Our results suggested that hypo-metabolism in a front-limbic network dysfunction is characterized by the cingulum and a front-occipital network dysfunction characterized by the occipital lobe, while an occipital-temporal network dysfunction characterized by the inferior longitudinal fasciculus.

Altered Empathy for Psychological and Physical Pain in Borderline Personality Disorder

Many patients with borderline personality disorder (BPD) experience difficulties in empathizing with others and are sensitive to social exclusion. Accordingly, the authors developed a novel Social Interaction Empathy Task to examine empathy for physical and psychological pain from first- and third-person perspectives. Fifty female patients with BPD and forty-eight controls matched for age and gender were included. Alexithymia was also measured. Patients with BPD rated neutral and psychologically painful situations as more painful than healthy controls, and patients with BPD rated psychological pain as more intense in the first-person perspective than in the third-person perspective. In contrast, controls did not differentiate between the perspectives and rated physical pain as most intense. The impact of early adversity on empathy for psychological pain was mediated by alexithymia. Increased sensitivity for psychological pain in BPD correlated with symptom severity. BPD is associated with altered empathy for pain, which is related to difficulties in reflecting emotional states.

The relationship between non-suicidal self-injury and alexithymia in borderline personality disorder: "Actions instead of words"

INTRODUCTION

Borderline personality disorder (BPD) is a serious mental illness that centers on the inability to effectively regulate emotions. A large amount of BPD patients engage in non-suicidal self-injury (NSSI). Given the NSSI contributes to serious health risks, it is important to know why some BPD patients engage in NSSI and others do not. A possible associated factor of NSSI in BPD may be alexithymia, which reflects difficulties in identifying and communicating feelings. Therefore the aim of the present study was to investigate whether NSSI was associated with alexithymia and whether this association still stood when controlling for gender and depression.

METHODS

The current study explored the relationship between NSSI and alexithymia in 185 BPD patients by means of the Self-Injury Questionnaire-Treatment Related and the Toronto Alexithymia Scale-20 (TAS).

RESULTS

Of the 185 BPD inpatients, 82.7% reported life-time NSSI, of whom 52.9% were still engaging in current NSSI; and 71.3% scored in the alexithymic range (cut-off score≥61). Current NSSI was significantly associated with TAS-total. Additionally, when considering the separate TAS subscales Difficulties Describing Feelings (DDF), Difficulties Identifying Feelings (DIF) and Externally Oriented Thinking (EOT), only DDF was significantly associated with NSSI, even after controlling for gender and depression.

CONCLUSION

These results suggest that NSSI in BPD patients is associated with alexithymia. More specific, difficulties describing feelings can lead to NSSI, independently of the depressive status of the BPD patient. The implications for clinical treatment of self-injurious BPD patients will be discussed.

A Meta-analysis on the Association Between Emotional Awareness and Borderline Personality Pathology

Theories on borderline personality pathology (BPP) suggest that characteristic emotional dysregulation is due to low levels of emotional awareness or alexithymia. This study is the first meta-analysis to systematically review and analyze the evidence. A systematic search of the literature was performed using PsycInfo, Web of Science/MEDLINE, and Scopus. The term "borderline personality disorder" was searched for in conjunction with "emotional awareness," "emotional self-awareness," "emotion recognition," "alexithymia," "emotional processing," "emotional granularity," "emotional intelligence," or "emotion regulation." All references in the included studies were reviewed for additional relevant articles. Thirty-nine studies were then evaluated in a random effects meta-analysis to assess the association between BPP and emotional awareness. An overall moderate positive association between BPP and emotional awareness was significant (r = 0.359; 95% CI [0.283, 0.431]; Z = 8.678; p < 0.001) along with high heterogeneity (Q(38) = 456.7; p < .001; I² = 91.7%). Studies comparing borderline personality disorder to healthy controls yielded a strong association (r = 0.518; 95% CI [0.411, 0.611]). No significant difference was found between studies using instruments for emotional awareness and those using alexithymia instruments. The strongest associations with regard to aspects of alexithymia were found for difficulties in identifying and describing emotions rather than externally oriented thinking. The results corroborate a moderate relationship between low emotional awareness and BPP. However, the mono-method self-report used in almost all studies is found problematic and precludes drawing definite conclusions. Since leading psychotherapeutic treatments strongly focus on increasing emotional awareness, future research should address this issue and further examine to what extent low levels of emotional awareness, particularly alexithymia, can be treated.

The measurement of alexithymia in children and adolescents: Psychometric properties of the Alexithymia Questionnaire for Children and the twenty-item Toronto Alexithymia Scale in different non-clinical and clinical samples of children and adolescents

This study had two aims. Firstly, the psychometric properties of the 20-item Toronto Alexithymia Scale (TAS-20) and the Alexithymia Questionnaire for Children (AQC) that measure the three dimensions of alexithymia (DIF, difficulty identifying feelings; DDF, difficulty describing feelings; EOT, externally-oriented thinking) were explored in various samples of children, adolescents or young adults to detect the best factor-structure and to examine if the Externally-Oriented Thinking (EOT) factor must be deleted or not. Secondly, the capacity for adolescents to distinguish between alexithymia and depression was studied using factorial analyses of items of self-report of alexithymia and depression scales. Four groups were examined (80 healthy children, 105 adolescents with various psychiatric disorders, 333 healthy older adolescents and 505 young adults recruited from universities). The first two groups filled out the AQC and the latter two the TAS-20. Confirmatory factorial analyses (CFA) showed that the two-factor model (DIF, DDF) provided acceptable fits and had significant advantages over the three-factor model (DIF, DDF, EOT). Low alpha coefficients for the EOT subscale were reported (range from 0.18–0.61). Except for the children sample, exploratory factorial analyses (EFA) were performed on the items of the TAS-20 or AQC without the EOT items and the Beck depression inventory-II (BDI-II) or the Zung Self-Rating Depression Scale (SDS). The items of the AQC and BDI-II or items of the TAS-20 and SDS loaded on separate factors with only a minor overlap suggesting that adolescents were able to differentiate alexithymia and depression when self-assessments were used. Alexithymia can be reliably assessed in adolescents using the TAS-20 or AQC without the eight items rating the EOT dimension.

An evaluation of the absolute and relative stability of alexithymia over 11years in a Finnish general population

OBJECTIVE

We investigated if alexithymia, a personality construct with difficulties in emotional processing, is stable in the general population.

METHODS

Altogether 3083 unselected subjects aged 30 and older in Finland completed the 20-item Toronto Alexithymia Scale (TAS-20) in the longitudinal Health 2000 and Health 2011 general population surveys (BRIF8901). The stability of alexithymia at the 11-year follow-up was assessed with t-tests, correlations, and separate linear regression models with base-line and follow-up age, gender, marital status, education, and 12-month depressive and anxiety disorders as confounders.

RESULTS

The mean score (SD) of the TAS-20 for the whole sample was 44.2 (10.4) in 2000 and 44.2 (10.9) in 2011 (p=0.731). The mean score of the TAS-20 subscale Difficulty Identifying Feelings increased by 0.3 points, Difficulty Describing Feelings decreased by 0.6 points and Externally Oriented Thinking increased by 0.3 points. The effect sizes of the changes varied from negligible to small. Age had little effect except for the group of the oldest subjects (75-97years): the TAS-20 mean (SD) score was 49.1 (10.1) in 2000 and 53.1 (10.3) in 2011 (p<0.001), the effect size for the increase was medium. TAS-20 score in 2000 explained a significant proportion of variance in TAS-20 score in 2011. Controlling for all baseline confounders improved the model incrementally; the same applied to controlling for confounders at follow-up. Baseline depression or anxiety disorders were not associated with the TAS-20 scores in 2011, whereas current diagnoses were.

CONCLUSIONS

According to our large longitudinal study both the absolute and relative stability of alexithymia assessed with the TAS-20 are high in the adult general population.

Alexithymia and psychosocial problems among Italian preadolescents. A latent class analysis approach

The study, conducted on Italian preadolscents aged 11 to 13 belonging to the general population, aims to investigate the relationship between the emotional functioning, namely, alexithymia, and the risk of developing behavioral and emotional problems measured using the Strength and Difficulty Questionnaire. The latent class analysis approach allowed to identify two latent variables, accounting for the internalizing (emotional symptoms and difficulties in emotional awareness) and for the externalizing problems (conduct problems and hyperactivity, problematic relationships with peers, poor prosocial behaviors and externally oriented thinking). The two latent variables featured two latent classes: the difficulty in dealing with problems and the strength to face problems that was representative of most of the healthy participants with specific gender differences. Along with the analysis of psychopathological behaviors, the study of resilience and strengths can prove to be a key step in order to develop valuable preventive approaches to tackle psychiatric disorders.

Substance abuse and personality disorder comorbidity in adolescent outpatients: are girls more severely ill than boys?

BACKGROUND

Substance use disorders (SUDs) constitute a major health problem and are associated with an extensive psychiatric comorbidity. Personality disorders (PDs) and SUDs commonly co-occur. Comorbid PD is characterized by more severe addiction problems and by an unfavorable clinical outcome. The present study investigated the prevalence of SUDs, PDs and common Axis I disorders in a sample of adolescent outpatients. We also investigated the association between PDs and SUDs, and how this association was influenced by adjustment for other Axis I disorders, age and gender.

METHODS

The sample consisted of 153 adolescents, aged 14-17 years, who were referred to a non-specialized mental health outpatient clinic with a defined catchment area. SUDs and other Axis I conditions were assessed using the mini international neuropsychiatric interview. PDs were assessed using the structured interview for DSM-IV personality.

RESULTS

18.3 % of the adolescents screened positive for a SUD, with no significant gender difference. There was a highly significant association between number of PD symptoms and having one or more SUDs; this relationship was practically unchanged by adjustment for gender, age and presence of Axis I disorders. For boys, no significant associations between SUDs and specific PDs, conduct disorder (CD) or attention deficit hyperactivity disorder (ADHD) were found. For girls, there were significant associations between SUD and BPD, negativistic PD, more than one PD, CD and ADHD.

CONCLUSIONS

We found no significant gender difference in the prevalence of SUD in a sample of adolescents referred to a general mental health outpatient clinic. The association between number of PD symptoms and having one or more SUDs was practically unchanged by adjustment for gender, age and presence of one or more Axis I disorders, which suggested that having an increased number of PD symptoms in itself may constitute a risk factor for developing SUDs in adolescence. The association in girls between SUDs and PDs, CD and ADHD raises the question if adolescent girls suffering from these conditions may be especially at risk for developing SUDs. In clinical settings, they should therefore be monitored with particular diligence with regard to their use of psychoactive substances. Trial registration The regional committee for medical research ethics for eastern Norway approved the study protocol in October 2004 (REK: 11395). Address correspondence and reprint requests to: Hans Ole Korsgaard, The Nic Waal Institute, Lovisenberg Diakonale Hospital, P.O. Box 2970 Nydalen, N-0440 Oslo, Norway; E-mail hansole.korsgaard@tele5.no.

Cross-cultural validation of the 20-item Toronto Alexithymia Scale in Chinese adolescents

WHAT IS KNOWN ON THE SUBJECT?: The TAS-20 is the most widely used self-reported questionnaire to assess the level of alexithymia in students and community and clinical samples. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The TAS-20-C exhibited high levels of reliability and validity, indicating that it is appropriate for the assessment of alexithymia in Chinese adolescents. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Screening adolescents who are at risk of alexithymia through the TAS-20 could help to perform necessary and effective precautions to decrease the adverse effects of alexithymia, such as the risks of developing depressive mood and behavioral problems.

ABSTRACT

Purpose The aim of this study was to examine the psychometric properties of the Chinese version of the 20-item Toronto Alexithymia Scale (TAS-20-C) in a sample of Chinese adolescents. Method Adolescents (n = 1260) recruited from three schools in mainland China completed the TAS-20-C, the somatization subscale of the Symptom Checklist 90 (SCL-90) and Center for Epidemiological Studies Depression Scale (CES-D). Five different factorial models of the TAS-20 were tested using confirmatory factor analysis (CFA). Cronbach's α, mean inter-item correlations and predictive validity were also evaluated. Results Among those five different factorial models, the four-factor structure model was suitable and invariant across gender and age in this sample. The TAS-20-C demonstrated adequate internal reliability. Gender and age accounted for insignificant amounts of variability in total TAS-20-C and factor scores. TAS-20-C total and subscale scores were correlated significantly with SCL-90 somatization subscale and CES-D. Girls scored higher than boys on difficulty identifying feelings (DIF) and pragmatic thinking (PR) subscales. DIF and lack of subjective significance or importance of emotions (IMs) subscale scores were higher among younger than among middle and older adolescents. Implications for Practice Validating the TAS-20 in adolescents is quite important to use it in evaluating adolescents' alexithymia, and screen those at risk of alexithymia.

Gender determines cortisol and alpha-amylase responses to acute physical and psychosocial stress in patients with borderline personality disorder

Borderline personality disorder (BPD) is characterized by affective instability, unstable relationships, and identity disturbance. We measured salivary alpha-amylase (sAA) and salivary cortisol levels in all participants during exposure to the Trier Social Stress Test (TSST) and an electric stimulation stress. Seventy-two BPD patients were compared with 377 age- and gender- matched controls. The State and Trait versions of the Spielberger Anxiety Inventory test (STAI-S and STAI-T, respectively), the Profile of Mood State (POMS) tests, and the Beck Depression Inventory (BDI), the Depression and Anxiety Cognition Scale (DACS) were administered to participants before electrical stimulation. Following TSST exposure, salivary cortisol levels significantly decreased in female patients and significantly increased in male patients compared with controls. POMS tension-anxiety, depression-dejection, anger-hostility, fatigue, and confusion scores were significantly increased in BPD patients compared with controls. In contrast, vigor scores were significantly decreased in BPD patients relative to controls. Furthermore, STAI-T and STAI-S anxiety scores and BDI scores were significantly increased in BPD patient compared with controls. DACS scores were significantly increased in BPD patient compared with controls. Different stressors (e.g., psychological or physical) induced different responses in the HPA and SAM systems in female or male BPD patients.

The role of language in emotion: predictions from psychological constructionism

Common sense suggests that emotions are physical types that have little to do with the words we use to label them. Yet recent psychological constructionist accounts reveal that language is a fundamental element in emotion that is constitutive of both emotion experiences and perceptions. According to the psychological constructionist Conceptual Act Theory (CAT), an instance of emotion occurs when information from one's body or other people's bodies is made meaningful in light of the present situation using concept knowledge about emotion. The CAT suggests that language plays a role in emotion because language supports the conceptual knowledge used to make meaning of sensations from the body and world in a given context. In the present paper, we review evidence from developmental and cognitive science to reveal that language scaffolds concept knowledge in humans, helping humans to acquire abstract concepts such as emotion categories across the lifespan. Critically, language later helps individuals use concepts to make meaning of on-going sensory perceptions. Building on this evidence, we outline predictions from a psychological constructionist model of emotion in which language serves as the "glue" for emotion concept knowledge, binding concepts to embodied experiences and in turn shaping the ongoing processing of sensory information from the body and world to create emotional experiences and perceptions.

Diazepam binding inhibitor and dehydroepiandrosterone sulphate plasma levels in borderline personality disorder adolescents

BACKGROUND

Borderline personality disorder (BPD) patients display a complex and heterogeneous clinical phenotype that plausibly implies variable underlying pathogenic mechanisms. A dysregulation of peripheral benzodiazepine receptors has previously been shown in BPD peripheral tissues, implying possible alterations of its ligand, the diazepam binding inhibitor (DBI) or of the downstream products of its activation, i.e. neuroactive steroids.

METHODS

The aim of this work consisted in assessing, by ELISA, fasting plasma levels of DBI and dehydroepiandrosterone sulphate (DHEA-S), including cortisol and the cortisol-to-DHEA-S molar ratio (CDR), in 17 BPD adolescents versus 13 healthy controls, testing the possibility that clinical scales related to depressive or anxious traits (CDI, STAI-Y) or to disease severity (BPDCL) might be associated with a selective dysregulation of these parameters.

RESULTS

DBI plasma levels were unchanged, while DHEA-S ones were significantly increased (approx. 70%) and the CDR decreased in BPD patients. No meaningful correlations with clinical variables emerged.

CONCLUSION

Our results indicate that a dysfunction of the neurosteroid system might be operative in BPD in spite of unchanged DBI plasma levels and that DHEA-S might represent a generalized trait marker for the altered stress response that is associated with this disorder.

The relationship between alexithymia, anxiety, depression, and internet addiction severity in a sample of Italian high school students

We aimed to assess whether Internet addiction (IA) severity was related to alexithymia scores among high school students, taking into account the role of gender differences and the possible effect of anxiety, depression, and age. Participants in the study were 600 students (ages ranging from 13 to 22; 48.16% girls) recruited from three high schools in two cities from Southern Italy. Participants completed a sociodemographic questionnaire, the Toronto Alexithymia Scale, the Internet Addiction Test, the Hamilton Anxiety Scale, and the Hamilton Depression Scale. The findings of the study showed that IA scores were associated with alexithymia scores, over and above the effect of negative emotions and age. Students with pathological levels of alexithymia reported higher scores on IA severity. In particular, results showed that difficulty in identifying feelings was significantly associated with higher scores on IA severity. No effect of gender was found. Implications for clinicians were discussed.

Regional cortical thinning may be a biological marker for borderline personality disorder

OBJECTIVE

We investigated cerebral cortical thickness and its relation to measurements of difficulties with identifying and describing emotions in patients with borderline personality disorder (BPD).

METHOD

Eighteen SCID-II-diagnosed female patients with BPD and 21 healthy female controls underwent magnetic resonance imaging and completed the Toronto Alexithymia Scale (TAS). First, regional cortical thickness across the cerebral surface was compared between patients and healthy controls. Then, analyses of the association between cortical thickness and TAS subscales were performed in patients.

RESULTS

Compared with controls, patients exhibited clusters of significantly reduced cortical thickness in the left medial and lateral prefrontal cortex, left temporoparietal junction, bilateral temporal poles, and bilateral paracentral lobules. Significant negative associations were observed between cortical thickness and the 'Difficulties Describing Feelings' TAS subscale (DDF) scores in patients. The anatomical distribution of these associations was highly overlapping with the group differences in cortical thickness.

CONCLUSION

The pattern of regions exhibiting cortical thinning in patients resembles a network of cortical structures repeatedly shown to be involved in social cognition. The results of the DDF analyses suggest that the thinning may partly be related to interpersonal dysfunction in patients with BPD. The pattern of thinning may represent a potential biological marker for BPD.

Prosodic abnormalities in schizotypal personality disorder

OBJECTIVE

Patients with schizophrenia speak with blunted vocal affect but little is known regarding the prosody of persons with schizotypal personality disorder (SPD). This work examined expressive prosody in SPD, its relationship to brain structure, and outlined a framework for measuring elements of prosody in clinical populations.

METHODS

Twenty-eight antipsychotic-naïve SPD subjects were matched with 27 healthy comparison (HC) subjects. Subjects read aloud short sentences and responded to probes to record both predetermined and self-generated speech samples. Samples were analyzed acoustically (pause proportion, duration, attack, and pitch variability) and subjectively by raters (amount of pauses, degree of emotion portrayed, and how much they wanted to hear more from the subjects) on paragraph, sentence, word, word-fragment, and syllable levels. Alexithymia and ability to self-monitor behavior were compared between groups. The pars opercularis was manually traced on structural MRI data.

RESULTS

SPD subjects' speech had significantly more pauses, was slower, had less pitch variability, and expressed less emotion than HC subjects. Pitch variability correlated with socio-economic status achievement. There was no difference between groups in left or right pars opercularis volumes. A statistically significant correlation suggested that smaller left pars opercularis volumes in SPD subjects correlated with more pauses and less emotion. SPD subjects reported more alexithymia and difficulty self-monitoring their behavior compared with controls. In SPD subjects the high alexithymia correlated with raters not wanting to hear more from them and SPD subjects' inability to modulate their social behavior correlated with their having fewer friends. Thus, the SPD subjects exhibited insight.

CONCLUSIONS

SPD subjects displayed significant prosodic deficits that were measurable in speech samples as brief as a word-fragment. The determinants of these deficits are not known although these may include a dysfunctional pars opercularis. These data add to the nascent literature describing social cognition deficits in SPD.