Alexithymia as a mediator between attachment and the development of borderline personality disorder in adolescence

[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.

Attachment and alexithymia predict emotional-behavioural problems of institutionalized, late-adopted and community adolescents: An explorative multi-informant mixed-method study

OBJECTIVE

Compared to community adolescents (COM), adolescents placed in residential care (RC) or late adopted (LA) appear to show more emotional-behavioural problems. They also appear vulnerable in variables linked to emotional-behavioural problems, such as insecure-disorganized attachment and alexithymia. This study employs a mixed-method multi-informant approach to (1) compare adolescents placed in RC, LA and COM in emotional-behavioural problems, attachment and alexithymia and (2) investigate relationships and interplay of attachment and alexithymia concerning emotional-behavioural problems in these three groups.

METHOD

Participants were 174 adolescents (50 RC, 33 LA and 91 COM; Mage  = 15, 53% boys and 47% girls). Adolescents' internalizing and externalizing problems were assessed through both caregiver-reported and self-reported questionnaires, while attachment and alexithymia were assessed with a mixed method, using interviews and self-report questionnaires.

RESULTS

The results showed RC adolescents as more vulnerable in all variables, while LA and COM did not differ. Accounting for the group, attachment and alexithymia cumulatively predicted 25-43% of internalizing problems, and 19-43% of externalizing problems depending on the method of assessment or problems' informant (all p < 0.01). Alexithymia was both an independent predictor and interacted with preoccupied attachment in predicting internalizing problems, while no predictors were isolated for externalizing ones, and the group never indicate an effect on problems' rates.

CONCLUSIONS

The authors discuss the utility to maintain a research focus on attachment and alexithymia, also suggesting future directions of research. A need to determine potential distortions of results because of problems' informant and method of assessment is also highlighted.

Self-disgust in patients with borderline personality disorder. The associations with alexithymia, emotion dysregulation, and comorbid psychopathology

BACKGROUND

Self-disgust is a negative self-conscious emotion, which has been linked with borderline personality disorder (BPD). However, it has not yet been investigated in relation to both emotion dysregulation and alexithymia, which are recognized as crucial to BPD. Therefore, the aim of our study was to measure these variables and examine the possible mediational role of emotional alterations and comorbid anxiety and depression symptoms in shaping self-disgust in patients with BPD and healthy controls (HCs).

METHODS

In total, the study included 100 inpatients with BPD and 104 HCs. Participants completed: the Self-Disgust Scale (SDS), Disgust Scale - Revised (DS-R), Toronto Alexithymia Scale (TAS-20), Emotion Dysregulation Scale short version (EDS-short), Borderline Personality Disorder Checklist (BPD Checklist), State-Trait Anxiety Inventory (STAI), and Center for Epidemiologic Studies Depression Scale (CESD-R).

RESULTS

Inpatients with BPD showed higher self-disgust, alexithymia, emotion dysregulation, core and comorbid symptoms levels, and lower disgust sensitivity. Alexithymia, emotion dysregulation, and trait anxiety partially mediated between BPD diagnosis and self-disgust. The relationship between the severity of BPD symptoms and self-disgust was fully mediated by alexithymia, emotion dysregulation, depressive symptoms, and trait anxiety.

CONCLUSIONS

The results of our study may imply the contribution of emotion dysregulation, alexithymia, and comorbid psychopathology to self-referenced disgust in BPD.

Four attachment-based categories of emotion regulation in adolescent psychic troubles

Introduction

Emotion regulation is altered in many psychiatric disorders in adolescence, but the understanding of mechanisms that underlie this alteration is still poor.

Methods

The PERCEPT study explores alexithymia, empathy, facial emotion recognition (FER) and defence mechanisms in a sample of adolescents in psychiatric care (n = 61, 74% of girls, mean age = 15.03 y.o.), in relation with participants' attachment styles.

Results

Results revealed correlations between attachment dimensions and all of the emotion regulation variables, suggesting that attachment modalities have functional links with emotional regulation at its different levels: FER accuracy was inversely correlated with avoidant attachment, while affective empathy, difficulty in identifying feelings (alexithymia) and immature as well as neurotic defence mechanisms were positively correlated with anxious attachment. Moreover, attachment categories delineated distinct emotional perception profiles. In particular, preoccupied attachment included adolescents with the highest levels of facial emotion perception (sensitivity and accuracy) and of affective empathy, whereas detached attachment included adolescents with the lowest levels of these variables. Neurotic defence mechanisms and difficulty to identify feelings were correlated with preoccupied attachment; immature defence mechanisms and difficulty to describe feelings to others characterized fearful attachment.

Discussion

These results suggest that attachment categories underlie emotion regulation processes in psychiatric disorders in adolescence. Theoretical and clinical implications are discussed.

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.

Late Adolescents' Attachment to Parents and Peers and Psychological Distress Resulting from COVID-19. A Study on the Mediation Role of Alexithymia

The scientific literature has shown the key role played by attachment to parents and peers and difficulties in recognizing, processing, and regulating emotions (i.e., alexithymia) in the (mal-)adaptive psychological response to the COVID-19 pandemic during late adolescence. No study has yet explored the complex interplay between these variables. We recruited a sample of 454 late adolescents (Mage = 22.79, SD = 2.27) and assessed attachment to parents and peers, alexithymia, and peritraumatic distress due to COVID-19 through self-report instruments. Attachment to fathers and peers, but not to mothers, and alexithymia significantly predicted levels of peritraumatic distress. Alexithymia fully and partially mediated the effect of, respectively, attachment to mothers and attachment to peers on peritraumatic distress due to COVID-19. These findings suggested that intervention programs focused on the promotion of peer social relationships, supportive parent-adolescent relationships, and the ability to recognize and discriminate one's own and others' emotions are needed in helping late adolescents to face the current health emergency and preventing short- and long-term psychopathological consequences related to the COVID-19 pandemic.

Attachment, Mentalization, and Criterion B of the Alternative DSM-5 Model for Personality Disorders (AMPD)

BACKGROUND

The mentalization theory posits that interpersonal difficulties and maladaptive personality traits develop from an insecure attachment pattern with one's caregiver and corresponding deficits in mentalizing-the ability to understand others' and one's own mental states. Mentalizing deficits have been theorized as the basis for all psychopathology, with the paradigmatic case being Borderline Personality Disorder. Nevertheless, developments in the personality field indicate personality pathology is best represented dimensionally, and such a proposal was outlined by the Alternative DSM-5 Model for Personality Disorders (AMPD). Despite evidence linking the mentalization theory to personality disorders, however, it has yet to be applied to Criterion B of the AMPD. The aim of the present study was to evaluate the moderating role of mentalizing in the relation between attachment and Criterion B maladaptive trait function in a sample of undergraduates. We hypothesized a model in which: (1) attachment insecurity would be positively associated with the Negative Affectivity, Antagonism, and Disinhibition personality domains; (2) mentalizing ability would be negatively associated with these domains; and, (3) there would be an interaction effect between attachment and mentalizing when predicting these same domains.

METHODS

Personality domains were measured dimensionally via the Personality Inventory for DSM-5 (PID-5-SF), while the dependence and avoidance domains of attachment were assessed via the Relationship Questionnaire (RQ). Mentalizing ability was tapped by the Movie for the Assessment of Social Cognition (MASC). The AMPD personality domains and trait facets were examined as dependent variables; attachment dependence, attachment avoidance, and overall mentalizing ability were entered as independent variables; and interaction terms between mentalizing and each attachment dimension were used to test moderation via MANCOVAs.

RESULTS

Consistent with expectations, results indicated overall mentalizing moderated the relation between attachment avoidance and Negative Affectivity. Posthoc analyses revealed similar effects on the relations between attachment avoidance and the Emotional Lability, Hostility, and Perseveration trait facets; however, there were no significant moderation findings related to attachment dependence.

CONCLUSIONS

These results support the mentalization theory's application to Criterion B of the AMPD, particularly in relation to the links between Negative Affectivity and borderline-related traits, and encourage future research of dimensional maladaptive personality. They further bolster support for understanding maladaptive personality as a dimensional construct.

Personal Agency in Borderline Personality Disorder: The Impact of Adult Attachment Style

Background

Personal agency- the degree to which one believes they have control over their life- is thought to influence how people understand their interpersonal relationships. Links between adult attachment and personal agency are theoretically relevant to the experience of borderline personality disorder (BPD) but this has yet to be empirically examined. The present research examines the impact of personal agency and adult attachment styles for individuals meeting criteria for BPD.

Methods

Participants consented to an online community study examining measures of locus of control (as an index of personal agency), BPD, and adult attachment. Participants meeting criteria for BPD (N = 96; mean age = 30.63; 70.5% female) were compared to age-matched healthy controls (N = 96; mean age = M = 31.99; 89.0% female).

Results

Individuals who met criteria for BPD displayed lower personal agency and higher fearful and preoccupied attachment styles in their close relationships, compared to Controls. Controls reported greater personal agency and were more securely attached in their relationships. Using multiple mediation modeling, the indirect effect of personal agency on BPD was significant for preoccupied, fearful, and secure attachment, but was non-significant for dismissive attachment. Lower personal agency was associated with insecure adult attachment styles.

Conclusions

Findings highlight the previously unexplored relationship between BPD and personal agency and indicate that adult attachment style plays a significant role. Low personal agency may increase challenges for individuals with symptoms of BPD by exacerbating relationship difficulties. People in treatment for BPD may benefit from focusing on both relationship insecurity and its impact on their perceived personal control.

Gambling and Attachment: The Mediating Role of Alexithymia in Adolescents and Young Adults

Attachment and alexithymia play a central role in the appearance and persistence of pathological gambling and related comorbid addictive behaviours among adolescents and young adults. The aim of the present study was to explore the differences between problem gamblers and non-problem gamblers in gambling severity, spending, video gaming, alcohol and drugs use, attachment, and alexithymia, as well as the interaction among these variables. The study sample included 560 participants non-problem gamblers (mean age = 15.49 years) and 54 problem gamblers (mean age = 16.43 years). Gambling disorder (SOGS-RA), drugs, alcohol, video games and spending (MULTICAGE CAD-4), attachment (IPPA), and alexithymia (TAS-20) were measured. Student's t, Pearson's r, and multiple mediation analyses were conducted. Problem gamblers scored significantly higher in all substance and non-substance addictive behaviours and alexithymia; as well as significantly lower scores in mother and father attachment scales. Moreover, gambling was negatively associated to father and mother attachment, and positively associated to alexithymia. Finally, alexithymia was found to mediate between parental attachment and gambling, spending, videogame, drug and alcohol abuse, especially in the case of mother attachment. This study demonstrated that adolescent and young adult problem gamblers show higher comorbid addictions than non-problem gamblers, in the same way as higher levels of alexithymia and poorer father attachment. Given that higher comorbidity in early ages is associated with worse prognosis and higher psychopathology in adult life, early detection and treatment purposes becomes essential.

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.

The mediating role of alexithymia in the association between attachment styles and borderline personality symptomatology

Attachment insecurity and alexithymia are assumed as the probable causes of emotional dysregulation in patients with Borderline Personality Disorder (BPD). The present study was designed and conducted to examine the mediating role of alexithymia in the relationship between attachment styles and Borderline Personality Symptomatology (BPS). In this crosssectional study, 153 patients with BPD were selected using stratified random sampling among outpatients referring to the psychiatric clinics in three major cities of Iran. Also, they were evaluated through the 20-item Toronto Alexithymia Scale (TAS- 20), Attachment Style Questionnaire (ASQ), and BPD Severity Index (BPDSI). On-way ANOVA and then Scheffé post-hoc analysis revealed that the scores of BPS and TAS-20, together with the scores of preoccupied, fearful, and dismissing styles, were higher in the alexithymia group, whereas the scores of secure style were greater in the non-alexithymia group. Furthermore, the results of hierarchical multiple regression analysis showed that alexithymia mediated the association between secure, preoccupied, and fearful styles and BPS based on the model proposed by Baron and Kenny. Hence, modifying the alexithymia need to be a goal of psychotherapy. In this regard, changing the effects of the problematic attachment styles via increasing emotional awareness may be effective in modifying alexithymia and BPS.

Impaired cognitive self-awareness mediates the association between alexithymia and excitation/inhibition balance in the pgACC

BACKGROUND

Previous research showed that automatic emotion regulation is associated with activation of subcortical areas and subsequent feedforward processes to cortical areas. In contrast, cognitive awareness of emotions is mediated by negative feedback from cortical to subcortical areas. Pregenual anterior cingulate cortex (pgACC) is essential in the modulation of both affect and alexithymia. We considered the interplay between these two mechanisms in the pgACC and their relationship with alexithymia.

METHOD

In 68 healthy participants (30 women, age = 26.15 ± 4.22) we tested associations of emotion processing and alexithymia with excitation/inhibition (E/I) balance represented as glutamate (Glu)/GABA in the pgACC measured via magnetic resonance spectroscopy in 7 T.

RESULTS

Alexithymia was positively correlated with the Glu/GABA ratio (N = 41, p = 0.0393). Further, cognitive self-awareness showed an association with Glu/GABA (N = 52, p = 0.003), which was driven by a correlation with GABA. In contrast, emotion regulation was only correlated with glutamate levels in the pgACC (N = 49, p = 0.008).

CONCLUSION

Our results corroborate the importance of the pgACC as a mediating region of alexithymia, reflected in an altered E/I balance. Furthermore, we could specify that this altered balance is linked to a GABA-related modulation of cognitive self-awareness of emotions.

A Meta-analysis and Systematic Review of Emotion-Regulation Strategies in Borderline Personality Disorder

Emotion dysregulation is often considered a core characteristic of individuals with borderline personality disorder (BPD). With the development and strength of a contemporary affective-science model that encompasses both healthy emotion regulation (ER) and emotion dysregulation, this model has increasingly been used to understand the affective experiences of people with BPD. In this meta-analysis and review, we systematically review six of the most commonly studied ER strategies and determine their relative endorsement in individuals with elevated symptoms of BPD compared to individuals with low symptoms of BPD and healthy controls, as well as to individuals with other mental disorders. Results from 93 unique studies and 213 different effect-size estimates indicated that symptoms of BPD were associated with less frequent use of ER strategies that would be considered more effective at reducing negative affect (i.e., cognitive reappraisal, problem solving, and acceptance) and more frequent use of ER strategies considered less effective at reducing negative affect (i.e., suppression, rumination, and avoidance). When compared to individuals with other mental disorders, people with BPD endorsed higher rates of rumination and avoidance, and lower rates of problem solving and acceptance. We also review important contributions from studies of ER in BPD that we were unable to incorporate into our meta-analysis. We conclude by discussing how the pattern of using ER strategies in BPD contributes to emotion dysregulation and also the potential reasons for this pattern, integrating both Gross's extended process model of ER and Linehan's updated theoretical account on the development of emotion dysregulation.

Fatigue in Multiple Sclerosis Is Associated With Childhood Adversities

Fatigue is a common and disabling symptom in patients with Multiple Sclerosis (PwMS). Its pathogenesis, however, is still not fully understood. Potential psychological roots, in particular, have received little attention to date. The present study examined the association of childhood adversities, specific trait characteristics, and MS disease characteristics with fatigue symptoms utilizing path analysis. Five hundred and seventy-one PwMS participated in an online survey. Standardized psychometric tools were applied. The Childhood Trauma Questionnaire (CTQ) served to assess childhood adversities. Trait variables were alexithymia (Toronto Alexithymia Scale; TAS-26) and early maladaptive schemas (Young Schema Questionnaire; YSQ). Current pathology comprised depression (Beck's Depression Inventory FastScreen; BDI-FS) and anxiety symptoms (State-Trait Anxiety Inventory; STAI-state), as well as physical disability (Patient determined Disease Steps; PDDS). The Fatigue Scale for Motor and Cognitive Functions (FSMC) was the primary outcome variable measuring fatigue. PwMS displayed high levels of fatigue and depression (mean FSMC score: 72; mean BDI-II score: 18). The final path model revealed that CTQ emotional neglect and emotional abuse remained as the only significant childhood adversity variables associated with fatigue. There were differential associations for the trait variables and current pathology: TAS-26, the YSQ domain impaired autonomy and performance, as well as all current pathology measures had direct effects on fatigue symptoms, accounting for 28.2% of the FSMC variance. Bayesian estimation also revealed indirect effects from the two CTQ subscales on FSMC. The final model fitted the data well, also after a cross-validation check and after replacing the FSMC with the Chalder Fatigue Questionnaire (CFQ). This study suggests an association psychological factors on fatigue in Multiple Sclerosis. Childhood adversities, as well as specific trait characteristics, seem to be associated with current pathology and fatigue symptoms. The article discusses potential implications and limitations.

A mediational model linking perceptions of security, alexithymia and behavior problems of sexually abused children

BACKGROUND

Perceptions of security toward parents are related with internalized and externalized problems among victims of child sexual abuse (CSA). Alexithymia, which is difficulty in identifying and expressing feelings, is associated with the quality of parent-child relationships (Oskis et al., 2013) and behavior problems in children (Di Trani et al., 2013).

OBJECTIVE

The current study tested the mediational role of alexithymia in the relationship between perceptions of security toward parents and behavior problems among CSA victims.

PARTICIPANTS AND METHOD

Using a short-term multi-informant prospective design, 263 victims of CSA aged 6-12 years completed the Kerns Security Scale (Kerns, Klepac, & Cole, 1996), which evaluates perceived attachment security to mothers and fathers. Parents completed the Child Behavior Checklist (Achenbach & Rescorla, 2001) at Time 1 to provide baseline scores of behavior problems and again four months later. At Time 2, parents also assessed the children's alexithymia using the Children's Alexithymia Measure (Way et al., 2010).

RESULTS

Perceptions of security were both associated with alexithymia, as well as with internalizing and externalizing problems (p < .05). A mediational model showed that perception of security toward fathers outweighed the mother-child relationship in predicting children's alexithymia. Path analysis revealed that the father-child relationship predicted decreased behavioral problems at Time 2 through a lower level of alexithymia. The model explained 46.9% of internalizing problems and 56.1% of externalizing problems (p < .05).

CONCLUSIONS

The findings support the relevance of alexithymia as an intervention target for CSA victims and underscore the importance of the father-child relationship.

A qualitative analysis of emotion and emotion regulation in hoarding disorder

OBJECTIVE

The role of emotion regulation (ER) has been receiving increased attention in relation to various forms of psychopathology including hoarding disorder (HD). However, questionnaire designs are limited to finding associations of ER with symptoms or symptom groups, without finding out how such constructs might be involved in the disorder.

METHODS

This study was a qualitative investigation of ER in a clinical HD sample (N = 11).

RESULTS

Prominent themes provided support for ER difficulties in hoarding. In particular, difficulties with identifying and describing feelings, unhelpful attitudes toward the emotional experience, the use of avoidance-based strategies, and a perceived lack of effective ER strategies were prominent themes. Furthermore, emotional factors were identified as being associated with the onset and/or exacerbation of hoarding behavior, and possessions and acquiring behavior appeared to serve an ER function.

CONCLUSION

The current paper provides a nuanced account of the role of ER in hoarding difficulties.

Alexithymia in borderline personality disorder is not associated with deficits in automatic visual processing of negative emotional stimuli

Previous studies have suggested that alexithymia may be related to impairments in automatic emotion processing. While it is well established that alexithymia is highly prevalent in individuals with borderline personality disorder (BPD), it is unknown whether this is reflected by an altered automatic processing of emotional stimuli. In the present study we investigated visually evoked event-related potentials using neutral and negative images from the International Affective Pictures System in 26 BPD patients and 26 healthy controls. In line with previous reports, all subjects showed increased late positive potentials (LPP) for negative compared to neutral images. There were, however, no between-group differences at any time point. Crucially, there was no difference between alexithymic and non-alexithymic BPD patients in the expression of LPP. Our study is the first to show that automatic emotion processing in the visual domain appears to be normal in BPD and unaffected by alexithymia.

Attachment and Reflective Functioning in Women With Borderline Personality Disorder

Insecure attachment and impairments in reflective functioning (RF) are thought to play a critical role in borderline personality disorder (BPD). In particular, the mentalization-based model argues that insecure attachment indirectly accounts for increased BPD features, notably via disruption of RF capacities. Although the mediation relationship between attachment, RF, and BPD is supported by previous evidence, it remains to be directly tested in adults with BPD. In the current study, a sample of 55 female adult BPD patients and 105 female healthy controls completed a battery of self-report measures to investigate the interplay between attachment, RF capacities, and BPD clinical status. Overall, the results showed that BPD patients pre- dominantly reported insecure attachment, characterized by negative internal working models of the self as unlovable and unimportant to others, and decreased RF abilities. Our findings further indicated that actual RF capacities mediated the relationships between adult insecure attachment and BPD clinical status.

The role of maternal care in borderline personality disorder and dependent life stress

BACKGROUND

Borderline Personality Disorder (BPD) affects 0.9%-3.2% of adolescents, and more than 20% of inpatient adolescents. Life stress has been linked to BPD across the lifespan, and previous research in adults has linked BPD to dependent stress (i.e., stress induced by the individual). However, prior research has not examined dependent stress alongside BPD in adolescents. Additionally, the potential protective effect of maternal care has not been considered in this relation. This study tested a moderation model expecting that (1) BPD would be positively associated with dependent life stress, (2) maternal care would be negatively associated with BPD, and (3) maternal care would moderate the relation between BPD and dependent life stress.

METHOD

The sample consisted of 184 adolescents recruited from an inpatient psychiatric facility serving a diverse population in the Southwestern United States. Dependent life stress, BPD, and maternal care were measured using the UCLA Life Stress Interview, DSM-IV Childhood Interview for BPD, and Kerns Security Scale, respectively.

RESULTS

Results supported the first two hypotheses; BPD diagnosis was significantly, positively associated with dependent life stress, and negatively associated with maternal availability and dependability. Contrary to the third hypothesis, no significant evidence that maternal care acts as a buffer in the relation between BPD and dependent life stress was found.

CONCLUSIONS

Although maternal care was not found to moderate the association between BPD and dependent life stress, results supported previously found relations between BPD, dependent life stress, and maternal care, and did so within a diverse inpatient adolescent sample.

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.

Frontal EEG asymmetry in borderline personality disorder is associated with alexithymia

BACKGROUND

Frontal EEG asymmetry is a widely studied correlate of emotion processing and psychopathology. Recent research suggests that frontal EEG asymmetry during resting state is related to approach/withdrawal motivation and is also found in affective disorders such as major depressive disorder. Patients with borderline personality disorder (BPD) show aberrant behavior in relation to both approach and withdrawal motivation, which may arguably be associated with their difficulties in emotion processing. The occurrence and significance of frontal EEG asymmetry in BPD, however, has received little attention.

RESULTS

Thirty-seven BPD patients and 39 controls underwent resting EEG and completed several psychometric questionnaires. While there were no between-group differences in frontal EEG asymmetry, in BPD frontal EEG asymmetry scores correlated significantly with alexithymia. That is, higher alexithymia scores were associated with relatively lower right-frontal activity. A subsequent analysis corroborated the significant interaction between frontal EEG asymmetry and alexithymia, which was moderated by group.

CONCLUSIONS

Our findings reveal that lower right frontal EEG asymmetry is associated with alexithymia in patients with BPD. This finding is in accordance with neurophysiological models of alexithymia that implicate a right hemisphere impairment in emotion processing, and could suggest frontal EEG asymmetry as a potential biomarker of relevant psychopathology in these patients.

Metacognition moderates the relationship of disturbances in attachment with severity of borderline personality disorder among persons in treatment of substance use disorders

OBJECTIVES

Borderline personality disorder traits have been observed to be linked with both insecure attachment styles as well as deficits in mentalizing and metacognition. Less is known, however, about how attachment style does or does not interact with deficits in mentalizing and metacognition to create, sustain, or influence levels of borderline personality disorder traits. In this study, we examined the hypothesis that metacognitive mastery, which is the ability to use knowledge about mental states of self and others to cope with distress and solve social problems, moderates the relationship of anxious attachment style with the severity of borderline personality disorder traits.

METHODS

Concurrent assessments were gathered of metacognitive mastery using the Metacognitive Assessment Scale Abbreviated, anxious attachment style using the Experiences of in Close Relationships Scale, and borderline personality disorder traits using the Structured Clinical Interview for DSM-IV Axis II Disorders. Participants were 59 adults in an early phase of recovery from substance use disorders in a residential setting.

RESULTS

Multiple regression revealed that metacognitive mastery moderated the relationship of anxious attachment style with the number of borderline personality disorder traits. A median split of the anxious attachment and metacognitive mastery scores was performed yielding 4 groups. An analysis of covariance revealed that participants with higher levels of anxious attachment and poorer metacognitive mastery had more borderline personality disorder traits did than the other groups after controlling for levels of psychopathology.

CONCLUSION

Insecure attachment may be associated with higher number of borderline personality disorder traits in the presence of deficits in metacognitive mastery. Patients with substance use and borderline personality disorder traits may benefit from treatment which addresses metacognitive mastery.

The aetiological and psychopathological validity of borderline personality disorder in youth: A systematic review and meta-analysis

Controversy surrounds the diagnosis of Borderline Personality Disorder (BPD) in youth. This meta-analysis summarised evidence regarding the aetiological and psychopathological validity of youth BPD (the extent to which youth and adult BPD share common risk factors and psychopathology). We identified 61 studies satisfying predetermined inclusion criteria. Statistically significant pooled associations with youth (19 years of age and under) BPD were observed for sexual abuse (all youth: odds ratio=4.88; 95% confidence interval=3.30, 7.21; children: OR=3.97; 95% CI=1.51, 10.41; adolescents: OR=5.41; 95% CI=3.43, 8.53); physical abuse (all youth: 2.79 [2.03, 3.84]; children: 2.86 [1.98, 4.13]; adolescents: 2.60 [1.38, 4.90]); maternal hostility/verbal abuse (all youth: 3.28 [2.67, 4.03]; children: 3.15 [2.55, 3.88]; adolescents: 4.71 [1.77, 12.53]); and neglect (all youth: 3.40 [2.27, 5.11]; children: 2.87 [1.73, 4.73]; adolescents: 4.87 [2.24, 10.59]). Several psychopathological features were also associated with youth BPD, including comorbid mood (3.21 [2.13, 4.83]), anxiety (2.30 [1.44, 3.70]) and substance use (2.92 [1.60, 5.31]) disorders; self-harm (2.81 [1.61, 4.90]); suicide ideation (all youth: 2.02 [1.23, 3.32]; children: 6.00 [1.81, 19.84]; adolescents: 1.75 [1.20; 2.54]) and suicide attempt (2.10 [1.21, 3.66]). Results demonstrate that adult and youth BPD share common aetiological and psychopathological correlates. This offers some support for the diagnostic validity of youth BPD and indicates the need for clinical recognition in this age group.

Does hostile rumination mediate the associations between reported child abuse, parenting characteristics and borderline features in adulthood?

This cross-sectional study investigated whether hostile rumination mediated the association between several indicators of a negative childhood environment (retrospectively reported child abuse and perceived parental care and overprotection) and borderline features. Community participants (N = 524) completed self-report measures in the laboratory. Results showed that adults exhibiting borderline features reported less parental care and more parental overprotection, as well as greater abuse. Additionally, hostile rumination statistically mediated the associations between all childhood environmental variables and borderline features, even controlling for depressive symptoms, alcohol use and impulsivity. Although cross-sectional data cannot test causal mediation, this pattern of results provides preliminary evidence that hostile rumination may partially account for the well-established connection between negative environments and borderline features. Future directions, including a discussion of longitudinal and experimental work that might help build on and strengthen the current findings, are explored.

How do maternal PTSD and alexithymia interact to impact maternal behavior?

Maternal interpersonal violence-related post-traumatic stress disorder (IPV-PTSD) is known to be associated with impairment of a mother's capacity to participate in mutual emotion regulation during her child's first years of life. This study tested the hypothesis that maternal difficulty in identifying feelings in self and other, as an important dimension of the construct of alexithymia, together with maternal IPV-PTSD, would be negatively associated with maternal sensitivity. Maternal sensitivity to child emotional communication is a marker of maternal capacity to engage in mutual regulation of emotion and arousal. Following diagnostic interviews and administration of the Toronto Alexithymia Scale, 56 mothers and their toddlers (ages 12-42 months) were filmed during free-play and separation/novelty-exposure. Observed maternal sensitivity was coded via the CARE-Index. Maternal IPV-PTSD severity, difficulty in identifying emotions, and lower socio-economic status were all associated with less maternal sensitivity, and also with more maternal controlling and unresponsive behavior on the CARE-Index.

Recent advances in the developmental aspects of borderline personality disorder

The aim of the current paper was to review the most recent advances in the developmental aspects of borderline personality disorder (BPD) over the last 3 years to highlight the most significant trends in the field. In so doing, we identify and discuss two exciting new trends: (a) an emphasis on the biological basis of adolescent BPD and (b) empirical evidence in support of long-held theories of the development of BPD. Together, these trends suggest that for the first time, empirical findings are beginning to emerge in support of complex and reciprocal biology × environment interactions over time in the development of BPD. We discuss the emerging literature and highlight the translational impact of this work for the assessment and intervention of adolescent BPD.

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.

Mothers' alexithymia, depression and anxiety levels and their association with the quality of mother-infant relationship: a preliminary study

OBJECTIVE

To evaluate the relationship between mothers and their developmentally normal infants in terms of maternal alexithymia, depression and anxiety, and marital satisfaction.

METHODS

Fifty children between 18 and 48 months of age, and their mothers, were referred consecutively to the Infant Mental Health Unit of Ankara University School of Medicine, Department of Child and Adolescent Psychiatry. The sociodemographic features of the families and the depressive symptoms, anxiety, marital satisfaction and alexithymia levels of the mothers were assessed. The relationships between children in normal developmental stages and their mothers were evaluated and rated using a structured clinical procedure.

RESULTS

There was a negative correlation between the mothers' alexithymia scores and the quality of the mother-infant relationship (p < 0.05). Mothers with high alexithymia showed higher depression and lower relationship qualities than mothers with low alexithymia, according to the correlation analysis. When depression and anxiety were controlled, high alexithymia levels were predictive of a low, impaired mother-infant relationship.

CONCLUSION

Since alexithymia is a trait-like variable which has a negative correlation with impairment in a mother-infant relationship, it must be investigated in the assessment of mothers' interactions with their babies.