Alexithymia in borderline personality pathology - From theory to a biosensor application
The PhD defence of Youri Derks will take place (partly) online and can be followed by a live stream.
Youri Derks is a PhD student in the research group Psychology, Health & Technology. Supervisors are prof.dr. E.T. Bohlmeijer and prof.dr. G.J. Westerhof, co-supervisor is dr. M.L. Noordzij, all from the Faculty of Behavioural, Management and Social Science (BMS).
Over the last decades, clinicians have come to acknowledge the presence of alexithymia and an inherent lack of emotional awareness to be an important element to address in treatment of patients with borderline personality pathology (BPP). Clinicians reason that limited emotional awareness in patients who are easily distressed and tend to react strongly and negatively to discrete emotional events, can be considered a catalyst for severe emotional dysregulation. Taken independently, there exist extensive and ever-increasing bodies of work on alexithymia, emotional awareness, and certainly BPP. Yet, there is a relative scarcity of empirical work that offers an integrative account on the development and status of alexithymia, its relation to emotional awareness and BPP. One could conclude there is a lot we have come to know, and there is a lot more we still do not. By employing what we did come to know, the options for effective treatment for BPP have improved markedly. Over the last 30 years or so, several specialised psychotherapeutic treatments for borderline personality disorder have been developed. However, despite these new treatments, BPP remains a source of high levels of emotional burden and suffering. Addition of mHealth to current - still traditional - forms of psychotherapy may be promising. Advances in mobile technology, constrained clinical care, and patient demand for contextualized, not stigmatizing, and low-cost alternatives are beginning to change the face of psychological assessment and interventions in an increasing pace. Currently, these rapid advances outpace the speed of academic research. As a result, many to most mHealth apps currently available to users lack a scientific basis and empirical support. There is a need for a proper scientific yet agile approach to develop mHealth for clinical purposes.
The overall aims of this thesis were to add to the understanding of the role of alexithymia and low emotional awareness, in particular with regard to borderline personality pathology (BPP), and to develop an mHealth intervention to better address alexithymia/low emotional awareness in treatment according to scientifically sound principles, and by making use of what we’ve learned about alexithymia in BPP. The research questions of this thesis are as follows:
- What are the characteristics of a comprehensive, transtheoretical account of the concept of alexithymia and its implications for patients and their treatment that can be learned from the evolution and development of the concept over time?
- To what extent are alexithymia and low emotional awareness associated to borderline personality pathology?
- Is it feasible to develop a biosensor-informed wearable app aimed to support training of emotional awareness in patients with borderline personality pathology by employing a design science paradigm?
These three research questions were addressed in the three parts of this dissertation: (I) (trans)theoretical account of alexithymia, (II) relationship between alexithymia and borderline personality pathology, and (III) development of a biosensor-informed wearable smartwatch/smartphone application to advance treatment of alexithymia and low emotional awareness. This final chapter starts with a summary of each chapter and continues with answering the three main research questions. From there, what follows are a discussion of the main overall findings and a transcending critical reflection on the whole of this thesis. Afterwards, implications for research and clinical practice, general strengths and limitations, and possible future directions are discussed. It concludes by sharing a personal reflection on the position of a scientist-practitioner.
Part I: (Trans)theoretical account of alexithymia
In Chapter 2 we explored the origins and development of the concept of alexithymia up until its present-day form. Based on a scoping review of the literature, we described three ‘eras’ of alexithymia research with an emphasis on recent developments. The concept of alexithymia emerged out of clinical observations (era 1) and became enriched with psychodynamic and later cognitive theories that drew on research on personality and personality traits (era 2). In the current, third era there is a gradual shift towards a more medically oriented, affective-neuroscientific approach. There is consensus that a lack of emotional awareness is at the core of alexithymia. We discussed the most common diagnostic tools and provided some guidelines for the psychotherapeutic treatment of alexithymia. One guideline is that it is essential for the clinician to accurately tailor interventions to the level of emotional awareness of the patient. In case of alexithymia, that would be at the level of personal bodily experiences. We concluded that despite the developments and advances in the understanding of alexithymia, there is a need for deepening the knowledge of the psychological and neuroscientific processes underlying alexithymia.
Part II: Relationship between alexithymia and borderline personality pathology
To find out whether an association between borderline personality pathology and low emotional awareness or alexithymia indeed exists, we conducted a meta-analysis that was described in Chapter 3. This study was the first meta-analysis to systematically review and analyse the evidence on the association between BPP and emotional awareness – including alexithymia. 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, involving 8321 subjects in total, were then evaluated in a random effects meta-analysis to assess the association between BPP and emotional awareness. The analysis showed an overall moderate positive association between BPP and emotional awareness, along with high heterogeneity. When including only studies in which a patient group with borderline personality disorder was compared to healthy controls, the overall association between BPP and emotional awareness was moderate to strong. Comparison of studies using instruments for emotional awareness and those using alexithymia instruments yielded no significant differences, meaning the overall association was not dependent on whether alexithymia or emotional awareness was assessed. Regarding the specific characteristics of alexithymia, strongest associations were found for difficulties in identifying and describing emotions, or affect awareness, rather than for externally oriented thinking. This supported the view that (at least) regarding BPP, ‘alexithymia’ is more about affect awareness than externally oriented thinking. The results of the meta-analysis supported a moderate relationship between low emotional awareness and BPP.
The results of the meta-analysis affirmed the clinical assumption of a relationship between BPP and alexithymia. However, they did not provide further direction on the nature of this relationship. Tentative explanatory models of borderline personality pathology (BPP) accredit alexithymia a key role in the broad psychological dysfunction and the detrimental behaviours that covary with increasing levels of BPP .
In the study described in Chapter 4, we explored these interrelationships and preliminarily tested the assumption that alexithymia functions as a transmission mechanism between borderline personality pathology and several indices of emotional dysregulation. We conducted a quantitative cross-sectional study in a population of adult psychiatric in- and outpatients who were in voluntary treatment for one or more psychological disorders. Self-injurious behaviours (SIB), dissociative experiences and depressive symptoms were used as indices for emotional dysregulation. Seventy-one patients (predominantly female and between 18 and 59 years of age) completed questionnaires on all variables. They also completed a structured clinical interview on alexithymia. BPP was assessed by using a dimensional, continuous scale, as a growing body of research shows that personality disorders are better represented dimensionally [11-16]. Regarding BPP, Spearman rank correlations confirmed data from other studies in the field, showing likewise associations with alexithymia, depressive symptoms, dissociative experiences, and SIB. Regarding alexithymia, our study confirmed associations of alexithymia with depressive symptoms and dissociative experiences. However, results of the study did not confirm a robust relationship of alexithymia with SIB. Apart from one weak positive association between alexithymia (measured by interview) and direct self-injurious behaviour in the past year (rs = .25, p < .05), none of the SIB measures correlated with either measure of alexithymia. This outcome was unexpected, as robust positive associations between SIB and alexithymia consistently have been reported in the literature . Regarding the main question, i.e., whether alexithymia acts as transmission mechanism between BPP and other variables, results of the study provided only limited support for the proposed explanatory model. Most notably, the study provided no support that alexithymia mediates the association between BPP and SIB. There was also no support for alexithymia mediating between BPP and dissociative experiences. However, the study did provide support for partial mediation by alexithymia in the relationship between BPP and depressive symptomatology.
Part III: Development of a biosensor-informed wearable application to advance treatment of alexithymia and low emotional awareness
Taking into account what we had learned so far, we decided to proceed with developing an mHealth intervention. This led to a set of two consecutive studies. Both studies were carried out within a setting for clinical treatment of personality disorders. In both studies we included patients in treatment and mental health professionals working at the treatment centre as ‘prospect users’ of the app.
The first of the two studies was described in Chapter 5. Via a tailored user experience design (UXD)-framework, we investigated the needs and requirements amongst BPD-patients in clinical treatment and their therapists regarding an ambulatory biofeedback app aimed to support patients in learning to better recognize changes in their emotional arousal. The study was grounded on a ‘design science’ paradigm [18, 19] and utilized a user centered, participatory design approach. We included 3 persons per group (6 in total). We combined two well-known, yet different User Centered Design (UCD) frameworks for eHealth development into a framework that helped to structure our approach and to support our goal. The model supported us in making explicit the stage of development (or ‘elements’), describing the output (or ‘products’) needed as input for the next phase of design, and the appropriate methods to obtain that output. This enabled us to map the context in which the app would be employed and visualised the prospect users of the future app. The study yielded a set of personas, user needs and design requirements, and mental models of the target user groups for a wearable biofeedback app. The results of the study showed that although the user needs of both the patient group and the therapist group converged to a considerable degree (for example that both stressed the need the application being discreet and unobtrusive), there also were some fundamental differences between groups. An example of the latter is that whereas therapists favoured a deep structure to organize the app, the patients advocated a broad structure. We also learned that if further development is to result in one user-friendly e-coach, it will need to incorporate (at least) two separate user environments. Within these user environments, it is important that the ‘look and feel’ is highly customizable per user. One other important requirement is that the application should include a function that enables patients to share their recorded data with their therapists.
In the subsequent UCD study described in Chapter 6, we continued and expanded the iterative approach on designing and testing the app with the goal to deliver a working version of the app that could be used in studies to test for clinical effectiveness. As in the previous study, this study involved close collaboration with and co-creation by (new) patients and mental healthcare professionals. In addition, we also included UCD experts as ‘users’. After expanding our UXD framework, the app’s usability was further tested and developed in tandem via a cyclic developmental process using multiple methods with multiple user groups (3-5 persons per group, per cycle). After 1 iteration in the first cycle of testing with patients, the basic functionality of the app was rated as acceptable. This waived the need for a major revision before starting the consecutive rounds of testing with mental health care professionals and UCD experts. On the Subjective Usability Scale (SUS), the patients rated the app as “Good” (average score of 78.8), whereas the therapists rated the app as “OK” (average score of 59.4). On a cognitive walkthrough, the UCD experts judged the app’s overall usability as between “OK” and “acceptable” (average score of 0.87). After finishing 3 testing cycles, in total 30 usability problems and needs were identified. All three user groups brought up usability problems and suggestions for improvement, of which some overlapped. UCD experts identified 20 usability problems. Patients identified 11 issues, and therapists identified 9 issues. Eight issues were mentioned by at least 2 groups. The UCD experts brought to our attention 14 themes or problems that were not mentioned by the other groups; the patients identified 6, and the therapists 2 unique themes. Most usability problems and needs could be addressed in the software revision that followed after the 3 cycles were finished. This process resulted in a stable prototype of the app that met most of the identified user requirements.
The current thesis delivers a comprehensive account on the background, development and current status of alexithymia and emotional awareness. It provides a systematic overview on how these phenomena relate to BPP and explores relationships to other clinical variables. To our knowledge, the meta-analysis described in chapter 2 was the first study to bring together and systematically examine the association of emotional awareness and borderline personality pathology (BPP). We also explored the associations of alexithymia and BPP with several of the key symptoms targeted in the treatment of BPP, such as self-injurious behaviours, dissociative experiences and negative mood symptoms. Furthermore, in this thesis we developed a mHealth biofeedback app to support the treatment of alexithymia. To our knowledge, it is one of the first in general and one of the very few to be at a stage of development ready for further research on clinical effectiveness, broader dissemination and implementation in the foreseeable future.
The thesis does not provide any definite answers on any of the topics – but still it adds to the existing knowledge. In fact, the depiction of the overall complexity of alexithymia, its treatment and the development of an mHealth intervention therefore may be considered the main gains. We learned what could be (part of) a contemporary definition of alexithymia, what seems to be part of it and what seems not to be, but also that there is still a lot about the construct of alexithymia that is unclear or unknown. We experienced that our tailored framework and chosen design methods were helpful in developing of an app – but we do not yet know for certain if these were more, comparably, or less efficient and effective than other possible frameworks and research methods. We know that our biofeedback app is experienced as potentially useful, but we yet have to implement it in real therapy and examine whether it shows clinical effectiveness.
 “a system of ‘scientific habits’ used by a group of scientists for the solution of scientific problems” 10. Masterman, M., The Nature of a Paradigm, in Criticism and the Growth of Knowledge: Proceedings of the International Colloquium in the Philosophy of Science, London, 1965, A. Musgrave and I. Lakatos, Editors. 1970, Cambridge University Press: Cambridge. p. 59-90.