Borderline Personality Disorder (BPD) is a severe mental health condition. Characterized by emotional instability, impulsive behavior, tumultuous relationships, and cognitive challenges, BPD can significantly impair daily life. Among its many symptoms, one of the most persistent and challenging is a profound sense of emptiness. This internal experience, often overshadowed by more visible symptoms like self-harm or impulsive actions, has received comparatively little attention in research and clinical settings.
Emptiness in BPD has been described in many ways, including feelings of hollowness, purposelessness, and disconnection from both oneself and others. It is not only difficult to define but also challenging to treat, as it rarely presents as an immediate crisis like other symptoms. Yet, studies suggest that this "quiet" symptom is deeply connected to more severe behaviors, such as self-harm and suicidal tendencies, as individuals may act impulsively to "fill the void." This article summarizes a landmark 24-year longitudinal study exploring how emptiness evolves over time in individuals with BPD compared to those with other personality disorders.
Despite its significance, emptiness has been understudied. It is an internal experience, making it harder to observe or measure. Unlike symptoms that prompt hospitalization, such as suicidal behavior, emptiness often flies under the radar. Yet, it is strongly associated with life-threatening behaviors and severe social impairments. Women with BPD, for example, have reported acting impulsively or engaging in self-harm to cope with feelings of emptiness.
Defining emptiness is another challenge. Some describe it as a "void" tied to loneliness or existential despair, while others see it as a sense of disconnection from self and others. Psychoanalysts refer to it as "inner impoverishment," while recent definitions emphasize feeling "mechanical" and disconnected from life. The sheer variety of definitions underscores its complexity. Measuring emptiness has also been difficult, with early tools like the Dysphoric Affect Scale relying on a single question about how often individuals feel empty. However, newer scales, such as the Subjective Emptiness Scale (SES) and Psychological Emptiness Scale (PES), now offer more nuanced assessments.
This 24-year study tracked 362 patients, including 290 individuals diagnosed with BPD and 72 with other personality disorders (OPD). All participants were initially inpatients at McLean Hospital in Massachusetts. The study excluded individuals with schizophrenia, bipolar disorder, or conditions causing psychiatric symptoms. Participants were aged 18-35 at the start and had average or above-average intelligence.
Researchers assessed symptoms, childhood experiences, and social functioning at baseline and every two years thereafter. Emptiness was measured using the Dysphoric Affect Scale, where participants rated the percentage of time they felt empty over the past month. Childhood adversity, protective factors, and comorbid mental health conditions like anxiety and PTSD were also evaluated.
At the start of the study, individuals with BPD reported feeling empty 58.5% of the time, compared to 41% for those with OPD. Over 24 years, these rates declined significantly, with BPD participants reporting emptiness 20.8% of the time at the final follow-up and OPD participants reporting it 9.7% of the time. Despite this improvement, over 60% of individuals with BPD still experienced some degree of emptiness after 24 years, highlighting its persistence.
Certain factors were linked to higher levels of emptiness in individuals with BPD:
Conversely, protective factors reduced the severity of emptiness:
The study found that social isolation plays a major role in sustaining feelings of emptiness. Individuals with BPD are more likely to experience social disconnection, which perpetuates these feelings. This aligns with theories suggesting that emptiness arises from a lack of connection with oneself and others.
The findings highlight the need for targeted interventions to address chronic emptiness in BPD. While existing treatments like Dialectical Behavior Therapy (DBT) and Mentalization-Based Therapy (MBT) focus on emotional regulation and interpersonal relationships, they could be adapted to address emptiness more directly. For example:
Additionally, early intervention for at-risk children—such as those who have experienced neglect or abuse—could prevent or mitigate the development of emptiness later in life. Programs that promote childhood competence, such as extracurricular activities and academic support, could also build resilience.
Emptiness is a complex, painful, and persistent symptom of Borderline Personality Disorder. While it tends to improve over time, it remains a significant challenge for many individuals even decades after diagnosis. By understanding the factors that contribute to or protect against emptiness, clinicians can develop more effective treatments and interventions. With a greater focus on this "quiet" symptom, there is hope for reducing its impact and improving the lives of those with BPD.
