Running head: ATTACHMENT, ALEXITHYMIA AND BPD

Alexithymia as mediator between attachment and development

of borderline personality disorder in adolescence

Anne-S. Deborde1,2,3, Raphaële Miljkovitch1,2, Caroline, Roy4, Corinne

Dugré-Le Bigre1,5,6,

Alexandra Pham-Scottez5,6,7,8, Maurice Corcos1,5,6,9, Mario

Speranza5,6,7,9,10

1 Department of Psychiatry for Adolescents and Young Adults, Institut MutualisteMontsouris, Paris2 CRAC-Laboratoire Paragraphe EA 349, Paris 8 University.3 Psychiatry Department, Cochin Hospital, Paris4 Laval University.5 University René Descartes- Paris V, Faculty of medecine, psychology laboratory6 Inserm U 6697 Paris Sud University8 Clinique des Maladies Mentales et de l’Encéphale, Sainte-Anne hospital, Paris9 UMR-S066910 Versailles Hospital, Child psychiatry department

Author Note:

Anne S. Deborde, Psychiatry department, Institut Mutualiste Montsouris.

Acknowledgments

This research was supported by a grant from the WYETH Foundation for Child and

Adolescent Health & by a grant from the Lilly Foundation. This work was

conducted in a European collaborative research project on borderline personality

disorder (European Research Network on Borderline Personality Disorders EURNET

BPD).

Correspondence concerning this sample paper should be addressed to

Raphaële Miljkovitch,

Université Paris 8, UFR Psychologie Pratiques Cliniques et Sociales, 2 Rue de la

Liberté, 93200 Saint-Denis France. E-mail: raphaele.miljkovitch@iedparis8.net

Alexithymia as a mediator between attachment and the development

of borderline personality disorder in adolescence

Abstract

Insecure attachment and the inability to identify emotions

have both been put forward as possible explanations for

dysfunction of the emotional system in borderline personality

disorder (BPD). This study aimed to test a model according to

which the influence of attachment on the development of BPD in

adolescence is mediated by alexithymia. Borderline severity was

assessed by means of the SIDP-IV. Attachment and alexithymia were

measured respectively with the RSQ and the TAS-20. Mediation

analyses conducted on 105 participants (54 BPD and 51 matched

controls) suggest that the role of security and negative model of

self (i.e. preoccupied and fearful attachment styles) in the

development of BPD symptoms are mediated by alexithymia.

Keywords: Attachment, alexithymia, borderline personality disorder

Borderline Personality Disorder (BPD) is characterized by intense

and labile emotions, significant conflict in interpersonal

relationships, and extreme behavioral impulsivity, which often

breaks out during adolescence (Roberts, Attkisson & Rosenblatt,

1998). Authors such as Linehan, Heard, & Amstrong (1993),

Corrigan, Davidson, & Heard (2000), and Silk (2000) posit that

borderline patients suffer extreme disturbances in mood

regulation. Linehan (1987) describes this emotional dysregulation

as great sensitivity to emotional stimuli, great emotional

intensity and slow return to emotional baseline (see also Crowell,

Beauchaine & Linehan, 2009 and Kuo & Linehan, 2009). Studies have

indeed evidenced associations between BPD and emotion

dysregulation (e.g. Gratz, Rosenthal, Tull, Lejuez, & Gunderson,

2009), yet data on the developmental pathways leading to this

dysregulation are still lacking.

The inability to identify emotions such as anger, fear, or

shame has been put forward as a possible explanation for emotional

dysregulation (Linehan et al., 1993). This inability relates to

the concept of alexithymia. Alexithymia is a personality construct

characterized by a difficulty in identifying and describing

feelings, a lack of fantasy, and a concrete and externally-

oriented thinking style (Sifneos, 1973, Taylor, Bagby, & Parker,

1997). According to Frijda (1986), identifying emotions usually

serves an adaptive function by providing information about a given

situation, and the different actions that are possible in that

situation. It is assumed that borderline patients often cannot

identify what emotions they feel, and hence what caused the

emotions. This inability may increase distress and trigger a range

of dysfunctional behaviours characteristic of BPD, aimed at

reducing negative affects (eg. suicidal/self-harming behaviours).

The inability to identify feelings has been shown to be an

important component responsible for dysfunction of the emotional

system in BPD (Wolff, Stiglamayr, Bretz, Claas-Hinrich, &

Auckenthaler, 2007). It thus seems reasonable to consider

alexithymia as a risk factor for BPD. Several studies show

associations between alexithymia and BPD scores (Berenbaum, 1996;

Modestin, Furrer & Malti, 2004; see also Bach et al., 1994),

however these samples did not specifically include borderline

patients.

In turn, alexithymia may stem from untoward attachment

experiences. According to Linehan's etiological model for

borderline pathology (Linehan et al., 1993), invalidating

environments where the expression of private emotional experiences

is not tolerated impede the understanding and labelling of

emotions (see also Fonagy, Target, Gergely, Allen & Bateman,

2003). Several studies show negative associations between

alexithymia and attachment security (Hexel, 2003; Meins, 2008;

Montebarocci, Codispoti, Baldaro & Rossi, 2004; Troisi, D’Argenio,

Peracchio. & Petti., 2001; Wearden, Lamberton, Crook & Walsh,

2005). Also, experiences of childhood maltreatment and inadequate

parenting are common among borderline patients (see Widom, Czaja &

Paris, 2009 for a review). According to Fonagy & Bateman (2006),

both insecure attachment and dysfunctional affect regulation

constitute vulnerability factors for the development of BPD. In

the present model, we propose more specifically that alexithymia

mediates the effect of attachment on the development of BPD.

Although many studies show associations between attachment and

alexithymia (Hexel, 2003; Meins, 2008; Montebarocci et al., 2004;

Troisi et al., 2001; Wearden et al., 2005), and between the

inability to identify feelings and BPD symptoms (Berenbaum, 1996;

Modestin et al., 2004; Wolff et al., 2007), none examine the link

between attachment and BPD via alexithymia. In addition, previous

research on attachment, emotional regulation, and BPD has mostly

been conducted on adult samples (see Miller, Muelehnkamp, &

Jacobson, 2008). Research findings on adults cannot be transposed

to adolescents because their emotional consciousness is only

emergent (Lerner & Steinberg, 2004) and because it is a time when

support from parents decreases and autonomous emotion regulation

is just beginning to be expected (Allen & Manning, 2007).

Adolescence is also a key period because the struggle for autonomy

is likely to reactivate unresolved attachment-related issues

(Allen & Miga, 2010) and because it is the time when borderline

symptoms often appear.

The following hypotheses were therefore tested on an

adolescent sample: 1) BPD is associated with attachment; 2) BPD is

associated with alexithymia; 3) Alexithymia mediates the

association between attachment and BPD.

Method

Participants and procedure

To test these hypotheses, one group of borderline patients and

one group of non-clinical adolescents were recruited. The samples

were drawn from a European longitudinal research project (European

Research Network on BPD, EURNET BPD) investigating the diagnostic

stability of BPD from adolescence to young adulthood (13-18

years). The research network involved five academic psychiatric

departments specialized in adolescents and young adults in France,

Belgium, and Switzerland. This study was approved by the French

Ethical Committee (Comité de Protection des Personnes) and data

were collected in an anonymous database, accepted by the French

National Committee for Personal Freedoms (Commission Nationale

Informatique et Libertés).

Borderline participants were recruited in adolescent

psychiatry departments. Patients were considered for inclusion

when they presented at least five of the nine DSM-IV borderline

criteria according to their psychiatrist. Patients with psychotic

disorders were excluded from the study for feasibility reasons.

Among the patients selected, BPD diagnosis was verified after

administration of a semi-structured interview (SIDP-IV) confirming

DSM-IV criteria. Psychiatric comorbidity was explored using a

semi-structured interview assessing DSM-IV criteria (Kiddie-Sads).

The diagnostic interviews were conducted by a team of 5

clinical psychologists and psychiatrists experienced in the

assessment of DSM-IV Axis I and II disorders in adolescents. To

obtain high levels of reliability, the research team participated

in several training sessions, including the commented scoring of

videotaped interviews and a training session conducted by the

developers of the Kiddie-SADS (Boris Birmaher & Mary Kay Gill).

Final research diagnoses were established by the best-estimate

method on the basis of the interviews and any additional relevant

data from the clinical record according to the LEAD standard

(Pilkonis, Heape, Ruddy & Serrao, 1991). The inter-rater

reliability for SIDP-IV was calculated from independent ratings of

ten videotaped interviews. The Kappa coefficient for agreement on

the presence or absence of a BPD was very high (0.84) and the

values for the presence/absence of the other personality disorders

ranged from 0.54 to 1.

Because the number of male participants was too small (N=15),

and because borderline symptomatology varies according to gender

(Johnson et al., 2003), only female participants were included.

All participants, and at least one of their parents for those

under 18 years of age, gave their written informed consent. After

this screening procedure, all patients filled out self-report

questionnaires in their respective psychiatry departments.

Ninety-five female adolescents with a DSM-IV clinical

diagnosis of BPD were referred to the study by their

psychiatrists. The formal diagnosis of BPD according to SIDP-IV

criteria was confirmed for 74 participants. Twenty borderline

patients had incomplete data on the self-report questionnaires and

were excluded from the final sample of the study, which was

composed of 54 outpatients.

Because patients were mostly from the upper-middle classes and

were still studying, an advertisement for the study was placed in

schools and universities to recruit participants for the control

group. The procedure with the non-clinical sample was identical to

that with the borderline sample. Control participants were

screened in order to make sure they did not have BPD (according to

the SIDP-IV) or current or lifetime mental disorders (according to

the Kiddie-SADS). For better contrast, adolescents who had

consulted a psychiatrist or psychologist were also excluded from

the study. Fifty-one control participants matched for

socioeconomic variables were thus included.

There were no significant age differences between the two

groups (mpatients = 16.52; sd = 1.18; mcontrol = 16.35; sd = 1.04; t = -

0.76; NS). Regarding parental employment status, only 3 fathers

(all in the clinical group) and 8 mothers (4 in each group) were

unemployed. Three levels of education were considered: (a) some

secondary education, (b) some post-secondary education, (c) higher

education diploma. Most fathers had higher education diplomas (67%

among controls vs 57% among patients). Mothers from the control

group had more often had post-secondary education (49% vs 27%

among mothers of patients) while mothers of patients were more

likely to have a higher education diploma (41% vs 33% among

controls). Nevertheless, there were no significant differences

between the control and the clinical group concerning parental

education (X2= 5.73, NS for the mother; X2=3.96, NS for the

father).

Measures

The Structured Interview for DSM-IV Personality Disorders

(SIDP-IV, Pfohl, Blum & Zimmerman, 1995) was used to confirm BPD

diagnosis among patients and screen for personality disorders

among all participants. Borderline severity for each of the 9

criteria was coded as absent (0), subliminal (1), present (2) or

massive (3). Borderline severity scores thus varied from 0 to 27.

The SIDP-IV has shown good psychometric properties on adolescent

and young adult samples (Chabrol et al., 2002).

The Kiddie-SADS (Kaufman, Birmaher & Brent, 1996 ; see

Kaufman et al. 1997 for data on psychometric properties) was used

to verify the absence of psychiatric disorders among control

participants and to assess psychiatric comorbidity among patients.

Diagnoses were established according to DSM-IV criteria.

A brief ad hoc self report questionnaire was administered in

order to make sure control participants had never consulted for a

psychiatric disorder, and to obtain socio-demographic data (i.e.

parental employment status and education).

The 20-item Toronto Alexithymia Scale (TAS-20, Bagby, Parker &

Taylor, 1994) is a self-report scale composed of items ranging

from 1 ‘strongly disagree’ to 5 ‘strongly agree’. The 20 items of

the TAS are clustered into three factors corresponding to the

theoretical dimensions of alexithymia: (F1) Difficulty Identifying

Feelings, (F2) Difficulty Describing Feelings, and (F3)

Externally-Oriented Thinking. TAS-20 scores are reliable, and the

three-factor structure is replicable (Bagby, Parker & Taylor,

1994). The TAS-20 is currently the most widely used measure of

alexithymia and considerable work has gone into testing its

reliability and validity (Bagby et al., 1994; Parker, Taylor &

Bagby, 2003; Taylor, Bagby & Parker, 2003).

The Relationship Styles Questionnaire (RSQ, Bartholomew &

Horowitz, 1991) is a self-report instrument with 30 items rated on

a 5-point scale. It is designed to measure a four-category model

of adult attachment: secure, fearful, preoccupied, and dismissing

attachment. The mean rating for each of the four subscales is

computed, generating four continuous variables. Each attachment

style is characterized by a particular underlying model of self

and others (Schafer & Bartholomew, 1994), which can be scored as

two separate continuous variables. Construct validity of the self

and others dimensions has been demonstrated (Bartholomew, 1990),

as well as convergent and discriminant validity (Griffin &

Bartholomew, 1994). In addition, moderate to high test-retest

stability has been established (Schafer et al., 1994).

Statistical Analyses

Descriptive analyses were conducted in order to examine the

main characteristics of both controls and patients. Independent

sample t tests were used to explore differences between the two

groups.

Associations between attachment, alexithymia, and borderline

severity were examined using Pearson correlations. To test the

hypothesis that alexithymia mediates the association between

attachment and borderline severity, the model proposed by Baron

and Kenny (1986) was used. According to this model, mediation can

be established if four conditions are met: (1) the independent

variable (attachment) affects the dependant variable (BPD); (2)

the independent variable affects the mediator (alexithymia); (3)

the mediator affects the dependant variable after the effect of

the independent variable on the dependant variable is taken into

account; and (4) the effect of the independent variable on the

dependant variable is reduced when the effect of the mediator on

the dependant variable is taken into account. The mediation model

is a causal model: the mediator is assumed to cause the outcome

and not vice versa. The total population (54 BPD + 51 non-

clinical) was used to perform these analyses.

Results

Preliminary analyses

The majority of adolescents with BPD met the criteria for at

least one current Axis-I disorder (N=47; 87%). Eating disorders

were the most frequently observed comorbidity (N=24; 44%),

followed by mood disorders (N=21; 39%), substance use disorders

(N=9; 17%), anxiety disorders (N=6; 11%), and disruptive behavior

disorders (N=6; 11%). Borderline adolescents showed high rates of

comorbid Axis-II personality disorders: obsessive-compulsive

(N=21; 39%), avoidant (N=10; 19%), antisocial (N=7; 13%), paranoid

(N=7; 13%), dependant (N=5; 9%), histrionic (N=2; 4%), schizotypal

(N=2; 4%) and narcissistic (N=2; 4%) personality disorders. No

schizoid personality disorder was found, probably because

psychotic patients were excluded from the study.

Table 1 presents the main characteristics for each group

concerning borderline severity and mean scores on the self-report

questionnaires (TAS-20 and RSQ). Borderline severity scores in the

control group ranged from 0 to 9 (m = 2.24; sd = 2.59) whereas

those of patients varied from 10 to 27 (m = 16.61; sd = 1.18). The

alexithymia mean score in the clinical group was 57.75, which is

above the alexithymia cut-off score (56). The alexithymia mean

score in the control group was 49.78.

Main analyses

A series of t tests was conducted to examine differences in

attachment and alexithymia between the two groups (Table 1).

Analyses revealed that, compared to controls, borderline

adolescents had significantly higher alexithymia scores.

Borderline patients were also less secure, more fearful, more

preoccupied and had a more negative model of self. There were no

significant differences for the dismissing style and the model of

others.

Table 2 presents the correlation coefficients among the 6

attachment dimensions, alexithymia, and borderline severity. All

measures were inter-correlated except for dismissing attachment

and model of others, which were not associated with BPD and TAS

scores (see Table 2). The attachment scales associated with the

TAS-20 and with borderline severity (i.e. secure, preoccupied,

fearful, and model of self) were retained for the subsequent

mediation analyses. Table 3 presents the four mediation analyses

linking these attachment dimensions with borderline severity

scores.

A partial mediating effect of alexithymia was found between

secure attachment and borderline severity. Secure attachment

predicted low levels of both borderline severity (9.8%, β = -0.31;

p < .001) (condition 1) and alexithymia (6.2%, β = -0.25; p < .001)

(condition 2). While alexithymia was a significant predictor of

borderline severity (β = 0.40; p < .001) when secure attachment was

taken into account (Condition 3), secure attachment was less

related to borderline severity (β = -0.21; p < .05) when

alexithymia was taken into account (Condition 4).

A complete mediating effect of alexithymia was found between

fearful attachment and borderline severity. Fearful attachment

significantly predicted both borderline severity (5.4%, β = 0.23; p

< .05) (condition 1) and alexithymia (5.1%, β = 0.23; p < .05)

(condition 2). But fearful attachment no longer explained

borderline severity once alexithymia was taken into account,

whereas alexithymia did (β = 0.43; p < .001) (conditions 3 & 4).

No mediating effect of alexithymia was found between

preoccupied attachment and borderline severity.

Another partial mediating effect of alexithymia was also found

between model of self and borderline severity. Model of self

predicted both borderline severity (9.1%, β = -0.30; p < .005)

(condition 1) and alexithymia (3.8%, β = -0.20; p < .05) (condition

2) but model of self was less related to borderline severity (β = -

0.22; p < .05) when alexithymia was taken into account (Condition

4).

To summarize, the protective effect of secure attachment and

model of self for borderline severity was only partially explained

by low levels of alexithymia. The association between preoccupied

attachment and borderline severity was not mediated by

alexithymia. Conversely, the predictive power of fearful

attachment with regard to borderline severity is explained by

alexithymia (i.e. complete mediation).

Discussion

In accordance with previous findings on adults (Webb &

McMurran, 2008), these results show that borderline adolescents

are more alexithymic than their matched controls. As expected,

patients were also significantly more insecure than non-clinical

participants. As in previous research (Westen, Nakash, Thomas, &

Bradley, 2006; Lyons-Ruth, 2008), secure attachment was negatively

associated with borderline severity.

Mediation analyses suggest that secure attachment is a

protective factor in the development of BPD. This is consistent

with Bowlby's (1969/1982) view that secure attachment is central

to personality development. Results further suggest that this

protective effect is partly due to the ability to identify and

express emotions. Bowlby proposed that a secure base is necessary

for the exploration of internal states. This exploration allows

better identification of emotions, which in turn promotes mature

and efficient affect regulation (see also Gergely & Watson, 1996).

Conversely, because insecure attachment is associated with lack of

sensitive caregiving (see de Wolff & van IJzendoorn, 1997), the

findings also corroborate Linehan’s model (Linehan et al., 1993).

According to this model, the development of BPD occurs within an

invalidating environment in which emotional displays are

considered unwarranted, thus compromising the understanding and

labelling of emotions. The person thus fails to learn how to solve

the problems contributing to these emotional reactions, giving

rise to more extreme emotional, behavioral, and cognitive

dysregulation (see also Fonagy, Target, Gergely, Allen & Bateman,

2003).

Among the insecure attachment dimensions considered,

preoccupied and fearful attachment were associated with BPD.

Preoccupied and fearful attachments both imply a negative model of

self. Further analyses showed that a part of the effect of the

negative model of self on borderline severity is direct, whereas

another part is mediated by alexithymia. The RSQ (Bartholomew et

al., 1991) was developed according to Bowlby’s (1969/1982) concept

of internal working model (IWM). Depending on the quality of care,

people develop IWMs of self as more or less lovable and of others

as more or less reliable and loving. Batholomew (1990) proposed

that the negative model of self  (i.e. fearful and preoccupied

styles) relates to anxiety (whereas the negative model of others

relates to avoidance). Anxiety refers to high vigilance concerning

caregiver availability, frequent verbal or physical contact with

him/her, intense distress during separation, anger and resistance

at the caregiver’s return (Hazan & Shaver, 1987). Our findings

concerning the negative model of self offer a better understanding

of many BPD symptoms, such as anxiety and anger. Borderline

adolescents’ attachment styles can account for the constant

worrying about caregiver availability and the anger this leads to,

as well as intense and labile affects and relationships. Also,

people with a negative model of self behave in accordance with

caregivers’ expectations rather than with their true self. Proper

identification of feelings is thus compromised, rendering them

more vulnerable to borderline symptoms. This fits nicely with the

theory developed by Fonagy et al (2003), according to which an

"alien self" (Fonagy, Target & Gergely, 2000) —arising from

insensitive caregiving— added to limited reflective capacities,

constitutes the roots of BPD.

Although preoccupied and fearful attachment styles were both

predictive of borderline severity, alexithymia only mediated the

link between fearful attachment and borderline severity. What

differentiates fearful attachment from preoccupied attachment is

the model of others, negative for the first and positive for the

latter. People with a negative model of others expect rejection

from others when seeking comfort and reassurance. Avoidance of

closeness to minimize disappointment logically limits the sharing

of emotions. This is also consistent with Linehan's etiological

model of BPD (Linehan et al., 1993).

The current study has certain limitations that must be

considered. First, because control participants were selected as

having no psychiatric disorder, representativeness of this sample

is questionable. This procedure was nevertheless preferred so as

to obtain greater contrast between the clinical and non-clinical

groups and identify borderline specificity more clearly. In future

studies, comparisons with other disorders would also enable

understanding of the psychopathological pathways specific to

borderline adolescents.

Although the present borderline sample is quite large

compared to those of most studies on adolescents, only female

participants were included, thus limiting the generalizability of

our results. Future research examining the links between

attachment, alexithymia, and BPD is still needed to understand the

development of BPD among male adolescents. This seems particularly

useful given that borderline symptomatology varies significantly

according to gender (Johnson et al., 2003).

Thirdly, reservations can be made regarding the assessments.

Concerning alexithymia, even if the TAS-20 is the most widely-used

questionnaire, there is a growing consensus that the way in which

people represent and regulate emotions is, in part, implicit and

not accessible to self-knowledge (e.g. Westen & Blagov, 2007). In

this respect, self-reports, which call for explicit self-

knowledge, probably miss the crucial component of the way in which

people actually process affective states. The use of a more

objective measure (e.g. Observer Alexithymia Scale, Haviland,

Warren & Riggs, 2000) could provide a more reliable assessment of

affect regulation.

Attachment was also measured using only a brief self-report.

Thus, participants’ responses reflected subjective evaluations of

self rather than actual attachment strategies. Nevertheless,

subjective representations may be relevant in understanding the

processes at work in psychopathology. It should also be noted that

it is avoidance —rather than anxiety— that is likely to lead to

biased self-reports (Cassidy, 1994). In the present study,

borderline patients proved to have preoccupied and fearful (i.e.

anxious) rather than avoidant attachment styles.

In other studies, disorganized attachment has been identified

as a vulnerability factor for the development of BPD (Fonagy et

al., 2006, Lyons-Ruth, 2008). A task for future research would be

to examine mediation between attachment, alexithymia and BPD

including a measure of disorganization (eg. unresolved loss or

trauma, hostile/helpless state of mind).

Conclusion

In short, this study provides support for an etiopathogenic model

according to which part of the association between attachment and

borderline severity is mediated by alexithymia. This process

already seems to be at work during adolescence. Because in this

period of life emotional consciousness is only emergent, the

ability to reflect upon emotions could be expected to be limited.

Yet the present study suggests that inter-individual differences

with respect to the ability to identify and express emotions are

already determining factors for borderline symptomatology.

Therefore, therapies aiming to increase emotional consciousness

(eg., Dialectical Behavior Therapy, Linehan, 1987; Transference

Focused Psychotherapy, Yeomans, Clarkin & Kernberg, 2002;

Mentalization-Based Treatment, Bateman & Fonagy, 2006), which have

been developed for adults, could also reasonably be considered for

treatment of borderline adolescents.

References

Allen J.P., Miga, E.M. (2010). Attachment in adolescence: A move

to the level of emotion regulation, Journal of Social and Personal

Relationships, 27(2), 181-190.

Allen J.P., Manning N. From Safety to Affect Regulation:

Attachment from the Vantage Point of Adolescence. New

directions for child and adolescent development 2007, 117, 23-

39.

Allen, J. P. & Land, D. (1999). Attachment in Adolescence. J.

Cassidy & P. R. Shaver (Eds.), Handbook of Attachment Theory and Research,

(pp. 319-335). New York: Guilford.

Ainsworth, M.D.S., Blehar, M.C., Waters, E., & Wall, S. (1978).

Patterns of attachment: assessed in the Strange Situation and at home.

Hillsdale, NJ: Erlbaum.

Bach, M., de Zwaan, M., Ackard, D., Nutzinger, D.O., & Mitchell,

J.E. (1994). Alexithymia: relationship to personality

disorders. Comprehensive Psychiatry, 35(3), 239-243.

Bagby, R.M., Parker, J.D., & Taylor, G.J. (1994). The twenty-item

Toronto Alexithymia Scale. I. Item selection and cross-

validation of the factor structure. Journal of Psychosomatic Research,

38, 23-32.

Bagby, R.M., Taylor, G.J., & Parker, J.D. (1994). The Twenty-item

Toronto Alexithymia Scale. II. Convergent, discriminant, and

concurrent validity. Journal of Psychosomatic Research, 38, 33-40.

Baron, R.M., & Kenny, D.A. (1986).  The moderator-mediator

variable distinction in social psychological research:

Conceptual, strategic and statistical considerations. Journal of

Personality and Social Psychology, 51, 1173-1182.

Bartholomew, K. (1990). Avoidance of intimacy: An attachment

perspective. Journal of Social and Personal Relationships, 7, 147-178.

Bartholomew, K., & Horowitz, L. (1991). Attachment styles among

young adults: A test of a four-category model. Journal of Personality

and Social Psychology, 61, 226-244.

Bateman, A., & Fonagy, P. (2006). Mentalization based treatment: A practical

guide. Oxford: Oxford University Press.

Bateman. A. (2009). Efficacious Treatment for BPD: Commonalities and Differences.

11th International Congress, International Society for the Study of

Personality Disorders, New York, August 21 – August 23.

Berenbaum, H. (1996). Childhood abuse, alexithymia and personality

disorder. Journal of Psychosomatic Research, 41(6), 585-595.

Bowlby, J. (1969/1982). Attachment and loss: Vol 1. Attachment (2nd ed.).

New York: Basic books. Original work published in 1969.

Cassidy, J. (1994). Emotion regulation: influences of attachment

relationships. Monographs of the society for research in child development,

59, 228-283.

Cassidy, J., & Schaver, P.R. (1999). Handbook of attachment: Theory,

research, and clinical applications. New York: Guilford Press.

Chabrol, H., Chouicha, K., Montavany, A., Callahan, S., Duconge,

E., Szulman, H. (2002). Personality disorders in a nonclinical

sample of adolescents. L’Encéphale, 28, 520-524.

Corrigan F.M., Davidson, A. & Heard, H. (2000). The role of

dysregulated amygdalic emotion in borderline personality

disorder. Medical hypotheses, 54(4), 574-579.

Crowell, S.E., Beauchaine, T.P. Linehan, M.M. (2009). A biosocial

developmental model of borderline personality: elaborating and

extending Linehan’s theory. Psychological Bulletin, 135(3): 495-510.

De Wolff, M.S., & van Ijzendoorn, M.H. (1997). Sensitivity and

attachment: A meta-analysis on parental antecedents of infant

attachment. Child Development, 68, 571-591.

De Wolff, M.S., Stiglamayr, C., Bretz, H.J., Claas-Hinrich, L.,

Auckenthaler, A. (2007). Emotion identification and tension in

female patients with borderline personality disorder. Clinical

Psychology, 46(3), 347-360.

Dimeff, L. (2009). Efficacious Treatment for BPD: Commonalities and Differences.

11th International Congress, International Society for the

Study of Personality Disorders, New York, August 21 – August

23.

Fridja, N.H. (1986). The emotions. New York: Cambridge University

Press.

Fonagy,   P.,   Leigh,   T.,   Steele,   M.,   Steele,   H.,  

Kennedy,   R.,   Mattoon,   G.,   et   al.  (1999).   The  

relation   of   attachment   status,   psychiatric  

classification   and   response   to   psychotherapy.   Journal

of  Consulting  and  Clinical  Psychology,  64,  22-31.

Fonagy, P., Target, M., Gergely. (2000). Attachment and borderline

personality disorder: a theory and some evidence. Psychiatric Clinic

of North America, 23: 103-122.

Fonagy, P., Target, M., Gergely, G., Allen, J. G., & Bateman, A.

(2003). The Developmental Roots of Borderline Personality

Disorder in Early Attachment Relationships: A Theory and Some

Evidence. Psychoanalytic Inquiry, 23, 412-459.

Gergely, G., Watson, J.S. (1996). The social biofeedback theory of

parental affect-mirrorring: the development of emotional self-

awarness and self-control in infancy. The International journal of

psycho-analysis, 77, 1-31.

Gratz, K., Rosenthal, M., Tull, M., Lejuez, C., & Gunderson, J.

(2009). An experimental investigation of emotion dysregulation

in borderline personality disorder. Personality Disorders: Theory,

Research, and Treatment, (1), 18-26.

Griffin, D. W., & Bartholomew, K. (1994). Model of the self and

others: fundamental dimensions underlying measures of adult

attachment. Journal of personality and social psychology, 67, 430-445.

Guttman H., & Laporte, L. (2002). Alexithymia, empathy, and

psychological symptoms in a family context. Comprehensive

Psychiatry, 43(6), 448-455.

Gunderson, J. (1996). Borderline patient's intolerance of

aloneness: Insecure attachments and therapist availability. The

American Journal of Psychiatry, 153(6), 752-758.

Haviland, M.G., Warren, W.L., Riggs, M.L. (2000). An observer

scale to measure alexithymia. Psychosomatics, 41(5), 385-392.

Hazan, C., & Shaver, P.R. (1987). Romantic love conceptualized as

an attachment process. Journal of Personality and social psychology, 59,

270-280.

Hexel, M. (2003). Alexithymia and attachment style in relation to

locus of control. Personality and Individual Differences, 35, 1261-1270.

Johnson, D.M., Shea, M.T., Yen, S., Battle, C.L., Zlotnick, C.,

Sanislow, C.A., Grilo, C.M., Skodol, A.E., Bender, D.S.,

McGlashan, T.H., Gunderson, J.G., Zanarini, M.C. (2003). Gender

differences in borderline personality disorder: findings from

the collaborative longitudinal personality disorders study.

Comprehensive Psychiatry, 44 (4), 284-292.

Kaufman, J., Birmaher, B., & Brent, D. (1996). Kiddie Schedule for

Affective Disorders and Schizophrenia - Present and Lifetime Version (K-SADS-PL).

Pittsburgh, PA: University of Pittsburgh School of Medicine.

Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P,

Williamson D, Ryan N. (1997). Schedule for affective Disorders

and Schizophrenia for school-Age Children-Present and Lifetime

Version (Kiddie-SADS-PL) : initial reliability and validity

data. Journal of American Academy of Child and Adolescent Psychiatry, 36,

980-8.

Kuo, J., & Linehan, M. (2009). Disentangling emotion processes in

borderline personality disorder: Physiological and self-

reported assessment of biological vulnerability, baseline

intensity, and reactivity to emotionally evocative stimuli.

Journal of Abnormal Psychology, 118(3), 531-544.

Lerner RM, Steinberg L. (2004). Handbook of Adolescent Psychology

(Second Edition). Hoboken, N J: John Wiley & Sons.

Linehan, M. (1987). Dialectical behavior therapy for borderline

personality disorder: Theory and method. Bulletin of the Menninger

Clinic, 51, 261-276.

Linehan, M.M., Heard, H.L. & Armstrong, H.E. (1993). Naturalistic

follow up of a behavioral treatment for chronically

parasuicidal borderline patients. Archives of General Psychiatry,

50(12), 971-974.

Loas, G., Otmani, O., Fremaux, D., Lecercle, C., Duflot, M., &

Delahousse, J. (1996). Criterion validity, reliability and

cutoff scores of the Toronto Alexithymia Scales (TAS and TAS-

20). Encéphale, 12, 35-40.

Lyons-Ruth, K. (2008). Contributions of the mother-infant

relationship to dissociative, borderline, and conduct symptoms

in young adulthood. Infant Mental Health Journal, 29, 203-218.

Main, M. & Solomon, J. (1986). Discovery of an insecure

disorganized/disoriented attachment pattern: procedures,

findings and implications for the classification of behavior.

In T. Braxelton and M.Yogman (eds) Affective development in infancy.

Norwood, NJ: Ablex.

Miller A.L., Muehlenkamp J.J., & Jacobson C.M. (2008). Fact or

fiction: Diagnosing borderline personality disorder in

adolescents. Clinical Psychology Review, 28, 969-981.

Meins E.H.-W. (2008). Understanding alexithymia: Associations with

peer attachment style and mind-mindedness. Personality and Individual

Differences, 45, 146-152.

Mikulincer M., & Shaver P.R. (2007). Attachment in adulthood: structure,

dynamics, and change. New York: Guildford press.

Modestin, J., Furrer, R., Malti, T. (2004). Study on alexithymia

in adult non-patients. Journal of Psychosomatic Research, 56(6):707-

709.

Montebarocci, O., Codispoti, M., Baldaro, B., Rossi, N. (2004).

Adult attachment style and alexithymia. Personality and Individual

Differences, 36 (3), 499-507.

Roberts, R.E., Attkisson, C.C., Rosenblatt, A. (1998). Prevalence

of psychopathology among children and adolescents. American

Journal of Psychiatry, 155:6, 715-725.

Parker, J.D., Taylor, G.J., & Bagby, R.M. (2003). The 20-Item

Toronto Alexithymia Scale. III. Reliability and factorial

validity in a community population. Journal of Psychosomatic Research,

55, 269-275.

Pfohl, B., Blum, N., & Zimmerman, M. (1997). Structured Interview for DSM-

IV Personality: SIDP-IV. American Psychiatric Press, Washington, DC.

Pilkonis, P.A., Heape, C.L. Ruddy, J., Serrao, P. (1991). Validity

in the diagnosis of personality disorders: The use of the LEAD

standard. Psychological Assessment: A Journal of Consulting and Clinical

Psychology, 3(1), 46-54.

Schafer, E. & Bartholomew, K. (1994). Reliability and stability of

adult attachment patterns, Personal Relationships, 1, 23–43.

Sifnéos, P.E. (1973). The prevalence of alexithymic charasteritics

in psychosomatic patients. Psychotherapy Psychosomatic, 22, 255-62.

Silk, K.R. (2000). Borderline personality disorder: overview of

biological factors. Psychiatric Clinics of North America, 23, 61–76.

Steinberg, L. (2005). Cognitive and affective development in

adolescence. Trends in cognitive Sciences, 9, 69-74.

Taylor, G.J., Bagby, R.M., & Parker, J.D. (2003). The 20-Item

Toronto Alexithymia Scale. IV. Reliability and factorial

validity in different languages and cultures. Journal of

Psychosomatic Research, 55, 277-283.

Taylor, G.J., Bagby, R.M., & Parker, J.D. (1997). Disorders of

affect regulation, Alexithymia in medical and psychiatric

illness. Cambridge University Press.

Troisi, A., D’Argenio, A., Peracchio, F. & Petti, P. (2001).

Insecure attachment and alexithymia in young men with mood

symptoms. Journal of Nervous and Mental Disease, 189, 311–316.

Wearden, A.J., Lamberton, N., Crook, N., Walsh, V. (2005). Adult

attachment, alexithymia, and symptom reporting: An extension to

the four category model of attachment. Journal of Psychosomatic

Research, 58, 279-288.

Webb, D., & Mcmurran, M. (2008). Emotional intelligence,

alexithymia and borderline personality disorder traits in young

adults. Personality and Mental Health, 2, 265-273.

Westen, D.,& Blagov, P. S. (2007). A clinical-empirical model of

emotion-regulation: From defense and motivated reasoning to

emotional constraint satisfaction. In J. J. Gross (Ed.),

Handbook of emotion regulation (pp. 373–392). New York: Guilford

Press.

Westen, D., Nakash, O., Thomas, C., & Bradley, R. (2006). Clinical

assessment of attachment patterns and personality disorder in

adolescents and adults. Journal of Consulting and Clinical Psychology,

74(6), 1065-1085.

Widom C.S., Czaja S.J., & Paris J. (2009). A prospective

investigation of borderline personality disorder in abused and

neglected children followed up into adulthood. Journal of Personality

Disorders, 23(5), 433-446.

Wolf, S. Stiglmayr , C., Bretz, H.J., Claas-Hinrich, L., &

Auckenthaler, A. (2007). Emotion identification and tension in

female patients with borderline personality disorder. British

Journal of Clinical Psychology, 46 (3), 347-360.

Yeomans, F.E., Clarkin J.F., & Kernberg, O.F. (2002). A Primer of

Transference-Focused Psychotherapy for the Borderline Patient. Northvale, NJ:

Jason Aronson.

Table 1Characteristics of study participants: borderline severity, alexithymia, and attachment

styles

CONTROLSMean ± SD [Range]

PATIENTSMean ± SD [Range]

t

BPD 2.24±2.59 [0-9] 16.61±4.44 [10-27] -20.1****

TAS-20 49.78 ±9,28 [30-68]

57.75 ±11.24 [28-81]

-4.09****

RSQ Secure 3.33 ±0,41 [2.40-4,20]

3.00 ±0.51 [1,80-4,00]

4,33****

Fearful 2.63 ±0,79 [1.25-4,75]

3.02 ±0.89 [1,25- -4.49*

Dismissing 2.66 ±0,64 [1,40-3,80]

2.68 ±0,87 [1-5] -0,12

Preoccupied 3.13 ±0,71 [1-4,75]

3.46 ±0,79 [1,75- -2.26*

Model ofself

1.47 ±0,50 [1-2] 1.25 ±0,44 [1-2] 2.41*

Model ofother

1.81 ±0,39 [1-2] 1,71 ±0,46 [1-2] 1.25

Note. NS Non Significant; * p < .05; ** p < .01; *** p < .005; **** p< .001

Table 2Correlation coefficients between borderline severity, alexithymia, and attachment styles

BPD TAS-20

RSQ

Fearful

Dismissing Secure Preoccup

ied

Model ofself

Modelofother

BPD 1 .46*** .23* -.27 -.31**** .36**** -.30**

* -.76

TAS-20 .46*** 1 .23* -.01 -.25* .22* -.20* -.06Note. NS Non Significant; * p < .05; ** p < .01; *** p < .005; **** p

< .001

Table 3Regression analyses testing the mediating role of alexithymia in the relationship betweenattachment style and borderline severity

Predictedvariables

Variables in equation R2 total β

BPD Secure Style 9.8% -.31****

Alexithymia Secure Style 6.2% -.25**BPD Secure Style &

Alexithymia25.0%

Secure StyleAlexithymia

-.21*.40***

*BPD Preoccupied Style 12.7% .36***

*Alexithymia Preoccupied Style 4.9% .22*

BPD Preoccupied Style &Alexithymia

27.6%

Preoccupied StyleAlexithymia

.27***

.40****

BPD Fearful Style 5.4% .23*Alexithymia Fearful Style 5.1% .23*

BPD Fearful Style &Alexithymia

22.6%

Fearful StyleAlexithymia

.14NS

.43****

BPD Model of self 9.1% -.30***

Alexithymia Model of self 3.8% -.20*BPD Model of self &

Alexithymia25.0%

Model of self -.22*Alexithymia .41***

Note. NS Non Significant; * p < .05; ** p < .01; *** p < .005; ****p < .001