Borderline personality disorder (BPD) is a complex and often misunderstood mental health condition characterized by difficulties with emotional regulation, impulsivity, and unstable relationships.
One of the criteria for diagnosis is chronic feelings of emptiness.
While commonly discussed in clinical observations, empirical research on this experience has been limited.
A new systematic review published in PLOS ONE aimed to analyze the available literature on chronic emptiness in BPD to better understand this elusive symptom.
The review uncovered several key insights:
- Defining and measuring chronic emptiness has been a major challenge. Across nearly 100 studies, there was little consensus on what exactly chronic emptiness entails. This has likely contributed to mixed findings on its relationship to other BPD symptoms. Developing a clear definition and measurement tool is crucial.
- Theories suggest chronic emptiness stems from impaired connections with oneself and others. Some empirical studies support this – feelings of detachment from self and others were linked to emptiness. Further research explicitly testing this is needed.
- Chronic emptiness appears to underlie impulsivity and self-harm behaviors in BPD. Multiple studies found it precedes and potentially motivates these actions, perhaps as an attempt to avoid distress.
- It may be a distinguishing factor of “borderline depression.” Unlike typical depression, this involves anger, loneliness, and poor self-concept rather than guilt. Emptiness appears central.
- Remits slower than other BPD symptoms, taking 8-10 years on average. It could reflect a core, enduring problem or lack of treatment focus.
- Therapies targeting mentalization and mindfulness may reduce chronic emptiness by improving self-other connections. But direct testing is needed.
Source: PLoS One 2020
The Difficulty of Defining Emptiness in BPD
Chronic feelings of emptiness are currently one of nine diagnostic criteria for BPD.
However, this systematic review found major difficulties in even defining what this experience entails.
Across nearly 100 studies involving over 98,000 participants with BPD, there was little consensus on the core features of emptiness or agreement on its relationship to other BPD symptoms.
Factor analyses attempting to identify clusters of symptoms had highly variable results, placing chronic emptiness with different symptom combinations.
When looking at how well each criterion distinguished BPD, emptiness was alternately described as highly important and the least important factor.
Researchers have suggested this confusion reflects the lack of an operationalized definition and the difficulty of measuring an internal experience described as feeling like “nothing.”
This contributes to mixed findings and limits generalizability of results on chronic emptiness thus far.
Only one study has aimed to directly investigate the experience of emptiness transdiagnostically.
This study found it was defined by feelings of detachment from self and others, hollowness, disconnection, and unfulfillment.
More research is critically needed to create a clear conceptualization of emptiness in BPD specifically.
Borderline Emptiness as Disconnection from Self and Others
Despite definitional issues, theoretical models converge on the idea that chronic emptiness stems from impaired connections to oneself and others.
This results from unreliable early caregiving, hindering the development of an integrated identity and ability to regulate emotions.
Some empirical findings support chronic emptiness relating to identity disturbances and social dysfunction.
One study linked it to deficits in self-identity, while another found greater social impairment.
Other indications come from therapies that improve emptiness through strengthening self-other connections.
For example, increasing mindfulness and mentalization skills, which improve understanding of oneself and others, reduced chronic emptiness.
However, research explicitly testing if impaired connections underlie chronic emptiness in BPD has been limited.
Future studies directly evaluating this theory are important to firmly establish whether emptiness arises from detachment from self and others.
The Role of Emptiness in Self-Harm and Impulsivity in BPD
In addition to illuminating potential causes, research points to chronic emptiness precipitating serious behavioral problems in BPD.
Several studies found it commonly precedes self-harm and impulsive behaviors.
In one study, 67% of participants with BPD reported feeling empty before self-harming.
Emptiness may act as an intolerable affective state motivating efforts to avoid distress via self-injury.
This is further supported by findings that BPD patients with chronic emptiness showed more frequent impulsivity and self-harm over one year.
Qualitative reports also indicate patients attempt to “fill the void” of emptiness through impulsive actions.
Taken together, these studies suggest chronic emptiness may underlie and drive the self-destructive symptoms often associated with BPD.
Targeting this symptom could potentially impact downstream behaviors.
However, more controlled studies are needed to firmly establish a causal relationship between chronic emptiness, impulsivity, and self-harm.
Borderline Depression – A Distinct Experience
In addition to self-harm, chronic emptiness may contribute to a depressive experience distinct from typical mood disorders in BPD.
Known as “borderline depression,” this centers on loneliness, anger, and identity disturbances rather than usual feelings of guilt or worthlessness.
Multiple studies have found a “borderline depression” marked by poor self-concept, emptiness, abandonment fears, and identity confusion.
Compared to major depressive disorder (MDD), BPD depression displays a sense of “void” or “inner badness” rather than excessive guilt.
Experts hypothesize chronic emptiness may be integral to borderline depression, reflecting a loss of self-identity and disconnectedness from others.
This anaclitic depression is proposed as separate from other depressive disorders.
More research is required to firmly establish borderline depression as a distinct entity and the role of chronic emptiness within it.
But current evidence indicates the depressive experience in BPD is qualitatively different, with emptiness potentially at its core.
The Persistence of Emptiness Over Time in Borderline Personality Disorder
In addition to its relationships with other symptoms, chronic emptiness shows a persistent course that distinguishes it from more acute BPD criteria.
Multiple longitudinal studies have now demonstrated feelings of emptiness take the longest to remit among BPD symptoms, requiring 8-10 years on average.
It also shows high rates of recurrence over time.
Some have suggested this reflects a temperamental, treatment-resistant quality of emptiness.
However, it may also result from a lack of treatment focus on this challenging symptom.
Regardless of the cause, emptiness appears to endure over years and even decades in BPD.
Unlike crisis-driven symptoms like self-harm that fluctuate, emptiness seems to persist at a core level.
Developing specific treatment approaches targeting chronic emptiness may be key to disrupting its sustained course.
But first, a better understanding of this complex symptom is critically needed.
Treatment for Emptiness in BPD: Strengthening Connections with Self & Others
Only a handful of studies have examined treatment approaches to reduce chronic emptiness in BPD.
Mindfulness, mentalization skills, and addressing relational patterns have been hypothesized as helpful based on limited data.
For example, dialectical behavior therapy (DBT) combines mindfulness skills within a validating environment.
Both aspects may strengthen a sense of connection to self and others, in turn decreasing emptiness.
Likewise, boosting mentalization and reflective capacity could allow better understanding of personal emotions and relationships with others.
Transference-focused psychotherapy uses this approach to improve identity integration.
However, no studies have directly tested whether treatments alleviating emptiness do so by enhancing connections to self and others.
Developing and evaluating therapies targeting chronic emptiness in BPD remains an important goal for future practice.
Future Research of Chronic Emptiness in BPD
This thorough literature review highlighted significant gaps in knowledge around chronic emptiness in BPD.
It emphasized four key directions for future research:
- Arriving at an operationalized definition of chronic emptiness through in-depth qualitative research on patient experiences.
- Creating validated tools to reliably measure severity of chronic emptiness.
- Testing theories on emptiness stemming from impaired self-other connections.
- Developing and evaluating psychological treatments targeting chronic emptiness.
While often described in clinical accounts, chronic feelings of emptiness in BPD remain empirically elusive.
Progress requires confronting this void through rigorous research elucidating the nature, causes, and treatment of this complex symptom.
Advancing our understanding of emptiness can significantly improve the lives of those diagnosed with BPD.
References
- Study: Measuring the shadows: a systematic review of chronic emptiness in borderline personality disorder
- Authors: Caitlin E. Miller et al. (2020)
