Insights: How Emptiness Changes Over Time in BPD

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A chronic feeling of emptiness is thought to be one of the most persistent features of borderline personality disorder (BPD). Despite this,  little attention has been paid to it – both clinically and academically – compared to other BPD symptoms such as impulsivity and self-harm. Now a team from Boston University, Harvard Medical School, and McLean Hospital in Belmont have studied how emptiness is experienced by people with BPD in comparison to other personality disorders (OPD), in a pool of 362 participants over a 24-year-period. Their findings were published in the Journal of Affective Disorders.

Researcher and clinical psychology doctoral candidate Katherine Hein was part of the team, and we discussed the study and its findings with her.

A forgotten symptom?

Emptiness may have received less focus in the past because it is hard to define, and therefore difficult to understand. The research team describe it in their paper as “an intensely unpleasant emotional experience,”, and note that academics variously characterize it as a “void”, a “disconnection from both self and others”, and a “sense of going through life mechanically, purposelessly and numbly”. So why does it lack a common definition? “Unless you’ve personally experienced it” or had “many, many clients describe it to you,” suggests Hein, it is difficult to truly grasp.

The paper offers another possible reason for the lack of studies: emptiness is a private and internal symptom of BPD. Other aspects of the condition are often “more obvious and imminently life threatening than feeling empty”, though Hein stresses that “Emptiness does play a role in many maladaptive behaviours,”. Studies have shown that feelings of emptiness have a strong connection with suicidal and self-harm behaviours. A 2016 study by the University of Johannesburg, South Africa, found that women with BPD report acting impulsively to “fill a void”, while Hein’s own previous study, published in the journal Personality Disorders: Theory, Research and Treatment in 2024, has found emptiness is linked to binge-eating.

Assessing emptiness

For this study, 290 people with BPD and 72 people with OPD (all aged 18-35) were recruited when they were inpatients. Researchers assessed their mental health through semi-structured clinical interviews and questionnaires. At baseline, the Revised Childhood Experiences Questionnaire was used to collect data about difficult, as well as protective, experiences that occurred before the person was 18. Protective experiences included the five different types of emotionally supportive relationships (caregivers, non-caregiving adult relatives, adult non-relatives, friends, and siblings) and the eight different childhood competencies (academic success, athletic success, other extracurricular activities, leadership, work, hobbies, household responsibilities, and popularity).

Their mental health symptoms were then re-assessed every two years. On average, the participants with BPD felt empty about 59% of the time at baseline, compared to 41% for those with OPD. At the 24-year follow-up, those with BPD felt empty about 21% of the time, while for those with OPD, it was about 10%. Symptoms of emptiness for patients begin to level off for both groups at the 10-year mark since they were first admitted: “it could be that living out in the community for 10 years is where the natural course of symptoms starts to decline,” says Hein. “Or that being in treatment in the community for that length of time is when we’re starting to see the real gains, on average.”

A history of post-traumatic stress disorder (PTSD) appeared to exacerbate the emptiness: there was a 57% increase in time spent feeling empty for those with comorbid PTSD and BPD compared to those with BPD without PTSD at baseline. This may be due to dissociative experiences, which are a shared symptom between these two disorders. The researchers elaborate: “Individuals with PTSD who dissociate may spend greater lengths of time feeling empty as a result of their dissociative experiences due to the similarities between these two experiences,”.

More competencies in childhood, meanwhile, were linked to less severe emptiness in adulthood, which may be because they work as “building blocks” for the more advanced emotional regulation skills necessary to manage feelings of emptiness. Success in school or sport, for example, often depends on a child being able to manage their emotions – a skill that can shape how they learn to cope with feelings later in life.

One limitation of the study, however, was that all participants had initially been inpatients, so they were experiencing more significant difficulties at baseline. The researchers caution that this sample “may not reflect the diversity of people with BPD encountered in the community”.

How can therapists use the findings?

Hein hopes the paper will show therapists that many of the people they work with will continue to struggle with emptiness, and that the findings can be used to help generate of treatment goals. In the short-term, they can focus on the high-risk behaviors (such as non-suicidal self-injury and suicidal behavior), and in the long-term they can think about how to reduce emptiness.

While adult clients with BPD obviously can’t address their childhood competencies, finding something in their present-day lives that gives them a similar sense of purpose and ability may help relieve their emptiness. Hein encourages therapists to help their clients identify potential avenues for this: “whether it’s being a caretaker for children or aged parents, being a volunteer in the community, or being really good at the work you do, it’s about finding something in your life that you can really latch on to. Something that makes you feel you’ve accomplished something, or that gives you a sense of ownership.”

Hein also advises therapists to “figure out ways to ensure the work you are doing as a therapist is going beyond the therapy room itself: assigning homework, or brainstorming with them to find things that they find enjoyable, purposeful, and meaningful. It seems easy to say, ‘Oh you’re feeling empty? Let’s find ways to relieve depression or bring happiness,’ but I think this study shows that we need to go beyond thinking purely affectively to thinking a little more broadly in terms of competencies.”

Key findings:

• Despite significant decreases over time, emptiness remains a common feature for individuals diagnosed with BPD at the 24-year follow-up.

• Severity of emptiness was significantly higher at baseline for people with BPD than with OPD, but declined at a similar rate over time in both groups.

• A baseline history of PTSD significantly predicted the severity of emptiness over 24 years. Interventions that target past trauma could help reduce the severity of BPD and chronic emptiness.

• Childhood competencies were found to have a protective effect. Helping clients develop skills in the present can help reduce emptiness.