Measuring the shadows: A systematic review of chronic emptiness in borderline personality disorder

A general inductive approach to characterize transdiagnostic experiences of emptiness

BACKGROUND

Despite the pervasiveness of patient-reported emptiness and the high burden it carries, emptiness is poorly understood. In the current study, we used a general inductive approach to examine experiences with emptiness in a diagnostically diverse sample of treatment-seeking patients with severe and acute psychopathology. As a secondary aim, we also examined whether identified themes differed among patients with a primary diagnosis of borderline personality disorder or major depressive disorder.

METHOD

Participants (n = 150) ranged from 18 to 69 years old (M = 33.15, SD = 12.41; 79.3% non-Hispanic White; 57.3% females). All patients completed the borderline personality disorder module of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Personality Disorders and the Mini International Neuropsychiatric Interview. Interviewers documented patients' responses to follow-up questions. Patients were included in the study if they endorsed chronic feelings of emptiness and elaborations were documented.

RESULTS

We identified 10 themes associated with patient-reported emptiness: (1) purposeless, (2) lack of connection, (3) numbness, (4) self-deprecation, (5) lack of identity, (6) lack of motivation, (7) hopelessness, (8) lack of pleasure, (9) physical sensation, and (10) dissociation. Themes were consistent across diagnostic status, with one exception: patients with borderline personality disorder were more likely to report that emptiness was associated with dissociation relative to patients with major depressive disorder.

CONCLUSION

Our results suggest that emptiness may reflect a multifaceted and transdiagnostic construct. Identified themes may help to support the assessment of emptiness and can be used to guide individualized treatments.

Void and narrative in the clinic of addictions: A theoretical proposal

We propose a connection between the void and addiction via psychoanalysis and current developments in narration in the context of the psychoanalytic clinic. We maintain that the addicted subject is shaped in particular by a relationship to the void evolving from the disruptive effects of the narrative. Our modern era is marked by a parallel evolution towards an unbearable void, to be filled at all costs. The neo-liberal promise of 'filling' the void with consumer objects in turn feeds the illusion of a so-called freedom, based on alienation to the inseparable duos of growth/jouissance and productivism/consumerism. The void has a multidisciplinary heritage (philosophy, physics, art, psychology) underlining certain aspects of a dialectic of the void that fluctuates between nothing at all and everything as potential. Taking this dialectic into account allows us to construct a concept of the void centred around two types of void: a narrative void and an a-narrative void. We maintain that the toxic in addiction can be interpreted as a narco-narrative that is constructed upon an a-narrative void. The clinical implications and technical proposals are briefly explored as openings to a clinical consideration of the void in the field of addictology.

What aspects of mindfulness and emotion regulation underpin self-harm in individuals with borderline personality disorder?

BACKGROUND

Self-harm presents significant risk for individuals with borderline personality disorder (BPD). Both self-harm and BPD are associated with deficits in mindfulness and emotion dysregulation. Previous research suggests that thought suppression and emotional inexpressivity may underpin self-harm in people with BPD, suggesting potential links to self-harm functions common for those with BPD. More research is needed to strengthen our understanding of this relationship.

AIMS

This study examines how BPD symptoms, mindfulness, emotion dysregulation and self-harm functions are related.

METHODS

Australian community outpatients diagnosed with BPD (N = 110) completed measures of mindfulness, emotion dysregulation and self-harm functions. Serial mediation analyses were conducted to examine relationships between variables.

RESULTS

BPD symptoms, chronic emptiness, mindfulness skills, describing and non-reacting, emotion dysregulation areas of emotion regulation strategies and poor emotional clarity were associated with recent self-harm. Various combinations of describing, strategies and clarity mediated the path between emptiness and self-harm functions more likely to be endorsed by individuals with a diagnosis of BPD. Describing was associated with all but anti-suicide function, while strategies was associated with all but anti-dissociation.

CONCLUSION

The study highlights how individuals with BPD experiencing chronic emptiness may benefit from treatment targeting describing skills and adaptive emotion regulation strategies.

Self-Hatred: The Unaddressed Symptom of Borderline Personality Disorder

Individuals with borderline personality disorder (BPD) often report chronic, severe self-hatred. It is frequently experienced as immutable, seen as a barrier to recovery, and is associated with risk for self-injury and suicide attempts. Yet self-hatred remains a poorly understood, underdiagnosed, and undertreated presentation of BPD. In this concept article and review, we describe the nature of self-hatred in BPD and related disorders, propose a theory as to the development of self-hatred in BPD, review the assessments of and interventions for self-hatred, and consider next steps in the research, assessment, and treatment of self-hatred in BPD. Through increased awareness, understanding, and measures of self-hatred in BPD, new treatment paradigms can be developed to ensure more comprehensive recovery.

The Psychological Emptiness Scale: a psychometric evaluation

BACKGROUND

Feelings of emptiness are commonly reported as deeply distressing experiences. Despite established relationships between emptiness and many mental health difficulties, alongside self-harm and suicide, further study into this phenomenon has been restricted by vague definition and clinical measures with limited utility. Recently the first definition validated by individuals with lived experience of emptiness has been conceptualised, providing an opportunity to create a new measure of emptiness.

AIMS

This study aimed to psychometrically evaluate the 31-item Psychological Emptiness Scale (PES), identifying redundancy, and thus creating a psychometrically robust scale with optimised clinical utility.

METHOD

Utilising an online survey design, 768 participants completed the 31 items of the initial PES alongside other measures of mental health. Exploratory factor analysis was conducted, and item response theory employed to identify item redundancy and reduce test burden. Expert clinicians provided ratings of each item's clinical relevance and, combined with the psychometric analysis, led to the removal of a number of items. Confirmatory factor analysis was then undertaken. Reliability including test-retest, validity and sensitivity of the measure were evaluated.

RESULTS

A two-factor structure encompassing 'nothingness' and 'detachment' was identified, and found to have acceptable fit. The resulting 19-item PES was found to have internal consistency (α = 0.95), convergent validity and test-retest reliability.

CONCLUSIONS

This study demonstrated strong psychometric properties of the PES. The PES has potential to support research into the role of emptiness in psychological distress and treatment in clinical practice.

The prevalence and severity of loneliness and deficits in perceived social support among who have received a 'personality disorder' diagnosis or have relevant traits: a systematic review

BACKGROUND

Loneliness and struggles with unmet social needs are a common experience among people with 'personality disorder' diagnoses/traits. Given the impact of loneliness and poor perceived social support on mental health, and the importance of a sense of belonging for recovery, a systematic review examining the prevalence/severity of loneliness and deficits in perceived social support among people with 'personality disorder' diagnoses/traits is an essential step towards developing an intervention targeting the social needs of people with diagnoses/traits 'personality disorder'. Despite an extensive literature on loneliness and deficits of perceived social support among people with 'personality disorder' diagnosis/traits, to date there has been no systematic review of this evidence.

METHOD

We conducted a systematic review synthesising quantitative data on the prevalence/severity of loneliness and deficits of perceived social support among people with diagnoses/traits of 'personality disorder' in comparison with other clinical groups and the general population. We searched Medline, Embase, PsycINFO, Web of Social Science, Google scholar and Ethos British Library from inception to December 2021. We conducted quality appraisals using the Joanna Briggs Critical appraisal tools and rated the certainty of evidence using the Grading of Recommendation, Assessment, Development and Evaluation approach. A narrative synthesis was used describing the direction and strength of associations prioritising high quality studies.

FINDINGS

A final set of 70 studies are included in this review, most of which are cross-sectional studies (n = 55), based in the United States (51%) and focused on community samples. Our synthesis of evidence found that, across all types of 'personality disorders' (except 'narcissistic personality' traits), people with traits associated with 'personality disorder' or meeting criteria for a diagnosis of 'personality disorder', have higher levels of loneliness, lower perceived relationship satisfaction, and poorer social support than the general population or other clinical samples.

CONCLUSION

The quality of evidence is judged as low quality. However, given the distressing nature of loneliness and the known negative effects of loneliness on mental health and recovery, it is important for future research to explore mechanisms by which loneliness may exacerbate 'personality disorder' symptoms and the impact this has on recovery.

Understanding of Depressive Symptomatology across Major Depressive Disorder and Bipolar Disorder: A Network Analysis

Background and Objectives: Depressive symptoms are prominent in both major depressive disorder (MDD) and bipolar disorder (BD). However, comparative research on the network structure of depressive symptoms in these two diagnostic groups has been limited. This study aims to compare the network structure of depressive symptoms in MDD and BD, providing a deeper understanding of the depressive symptomatology of each disorder. Materials and Methods: The Zung Self-Rating Depressive Scale, a 20-item questionnaire, was administered to assess the depressive symptoms in individuals with MDD (n = 322) and BD (n = 516). A network analysis was conducted using exploratory graph analysis (EGA), and the network structure was analyzed using regularized partial correlation models. To validate the dimensionality of the Zung SDS, principal component analysis (PCA) was adopted. Centrality measures of the depressive symptoms within each group were assessed, followed by a network comparison test between the two groups. Results: In both diagnostic groups, the network analysis revealed four distinct categories, aligning closely with the PCA results. "Depressed affect" emerged as the most central symptom in both MDD and BD. Furthermore, non-core symptoms, "Personal devaluation" in MDD and "Confusion" in BD, displayed strong centrality. The network comparison test did not reveal significant differences in the network structure between MDD and BD. Conclusions: The absence of significant differences in the network structures between MDD and BD suggests that the underlying mechanisms of depressive symptoms may be similar across these disorders. The identified central symptoms, including "Depressed affect", in both disorders and the distinct non-core symptoms in each highlight the complexity of the depressive symptomatology. Future research should focus on validating these symptoms as therapeutic targets and incorporate various methodologies, including non-metric dimension reduction techniques or canonical analysis.

The Psychological Network of Loneliness Symptoms Among Chinese Residents During the COVID-19 Outbreak

Purpose

Social distancing measures implemented during the COVID-19 pandemic have contributed to increased levels of loneliness, but the specific interactions between loneliness symptoms in the context of the pandemic remain unknown. This study characterized the psychological network of loneliness symptoms in residents during the initial wave of COVID-19 outbreak in China.

Patients and Methods

The study recruited 8472 Chinese residents (61.5% women, aged 33.0±10.6 years) through online snowball sampling. The Six-item De Jong Gierveld Loneliness Scale (DJGLS) was used to measure loneliness symptoms. Central symptoms of and bridge symptoms between emotional and social loneliness subscales were identified based on centrality and bridge centrality indices, respectively. Network stability was examined using the case-dropping procedures.

Results

The nodes in the loneliness network were separated into two groups, corresponding to the social and emotional loneliness domains of the DJGLS. The strongest direction association was between "no reliable people" and "no trustworthy people" (edge weight=0.546). "No trustworthy people" has the highest node strength (1.047) in the loneliness network, followed by "emptiness sense" (0.767) and "no reliable people" (0.749). "Feeling of rejection" (1.672) and "no close people" (0.403) showed the first and second highest bridge strengths, respectively. Both the stability and accuracy tests supported robustness of the whole network.

Conclusion

Interventions targeting central symptoms "no trustworthy people" and "emptiness sense" and central bridge symptom "feeling of rejection" may be effective for alleviating the overall level of loneliness in pandemic-affected Chinese residents.

The comorbidity between Borderline Personality Disorder (BPD) and Generalized Anxiety Disorder (GAD): A systematic review and meta-analysis

Borderline personality disorder (BPD) is a psychiatric condition characterized by severe instability in affect, impulse control, and interpersonal functioning. Existing literature has confirmed that BPD is highly comorbid with other psychiatric conditions, including anxiety disorders. Despite this, little research has investigated the nature of the relationship between generalized anxiety disorder (GAD) and BPD. The aim of this systematic review and meta-analysis is to synthesize the literature concerning the prevalence and clinical outcomes of BPD and GAD comorbidity in adults. The following three databases were searched on October 27, 2021: PsycINFO, PubMed, and Embase. Twenty-four studies were included (n = 21 reporting on prevalence of the comorbidity, n = 4 reporting on clinical outcomes associated with the comorbidity), 9 of which were included in a meta-analysis. The meta-analysis showed that the pooled prevalence for current GAD in individuals with BPD was 16.4% (CI 95%: 1.9%; 66.1%) in inpatient samples, and 30.6% (CI 95%: 21.9%; 41.1%) in outpatient or community samples. The pooled lifetime prevalence of GAD in individuals with BPD was 11.3% (CI 95%: 8.9%; 14.3%) in inpatient samples, and 13.7% (CI 95%: 3.4%; 41.4%) in outpatient or community samples. Comorbidity between BPD and GAD was associated with worse outcomes on measures of BPD severity, impulsivity, anger, and hopelessness. In conclusion, this systematic review and meta-analysis indicate that comorbid GAD and BPD is highly prevalent, although the pooled prevalence rates should be interpreted with caution considering the large and overlapping confidence intervals. Further, this comorbidity is associated with worse BPD symptom severity.

Body modifications in borderline personality disorder patients: prevalence rates, link with non-suicidal self-injury, and related psychopathology

BACKGROUND

Borderline Personality Disorder (BPD) is a potentially severe personality disorder, characterized by difficulties in emotion regulation and control of behaviors. It is often associated with non-suicidal self-injury (NSSI). Borderline personality features have also been linked to body modifications (BMs). However, the prevalence of BMs, the link between BMs and NSSI, and between BMs and several psychopathology dimensions (e.g. borderline severity, emotion regulation, impulsivity …) remains understudied in patients with BPD. This study aims to fill this gap, and to provide further evidence on the link between NSSI and BMs.

METHODS

We used data from a psychiatric outpatient center located in Switzerland (n = 116), specialized in the assessment and treatment of BPD patients. Patients underwent several semi-structured interviews and self-report psychometric scales at the arrival, and the data were retrospectively analyzed.

RESULTS

We found that 70.69% of the patients had one piercing or more, and 69.83% were tattooed. The total score of body modifications and the total number of piercings score of piercings were significantly positively associated with NSSI and the SCID BPD total score. The association with the SCID score was mainly driven by the "suicide and self-damaging behaviors" item and the "chronic feeling of emptiness" item. A significant association was found between total number of piercings and emotion dysregulation. On the other hand, the self-reported percentage of body covered by tattoos score was specifically associated with the sensation seeking subscale of the UPPS-P.

CONCLUSION

This study provides evidence on the prevalence of BMs in BPD patients, and on the link between BMs and NSSI in this population, suggesting a role of emotion regulation in the link between both constructs. These results also suggests that tattoos and piercings may be differentially linked to specific underlying psychological mechanisms. This calls for further considerations of body modifications in the assessment and care of BPD patients.

The relationship between emptiness and suicide and self-injury urges in borderline personality disorder

INTRODUCTION

Suicide and self-injury (SSI) are pervasive among individuals with borderline personality disorder (BPD), yet little research has examined factors that increase SSI urges among those with BPD. Emptiness is a diagnostic criterion of BPD that is associated with SSI behaviors, but its impact on SSI urges in BPD is poorly understood. This study investigates the association between emptiness and SSI urges at baseline and in response to a stressor (i.e., reactivity) among individuals with BPD.

METHODS

Forty individuals with BPD participated in an experimental procedure where they rated their degree of emptiness and SSI urges at baseline and in response to an interpersonal stressor. Generalized estimating equations tested whether emptiness predicts baseline SSI urges and SSI urge reactivity.

RESULTS

Higher emptiness predicted higher baseline suicide urges (B = 0.006, SE = 0.002, p < 0.001), but not baseline self-injury urges (p = 0.081). Emptiness did not significantly predict suicide urge reactivity (p = 0.731) nor self-injury urge reactivity (p = 0.446).

CONCLUSION

Assessing and targeting emptiness may facilitate the reduction of suicide urges in BPD. Future research should investigate treatment strategies for reducing SSI risk among individuals with BPD via targeting emptiness.

Perceived social support as related to social wellbeing in patients with Emotionally Unstable Personality Disorder (EUPD)

Background

People diagnosed with EUPD also known as borderline personality disorder (BPD) experience different challenges in their lives. These challenges include compulsive behavior, irritability, depression, sadness, guilt, shame, loneliness, grandiosity, and feeling of worthlessness. It is noteworthy that such challenges trigger among them a self-destructive behaviour, in addition to social isolation, and impaired social relationships. It is also found to significantly impact their physical, mental, and social wellbeing. This study is a humble attempt to examine the role of perceived social support in improving the social wellbeing of BPD outpatients. Through the purposive sampling technique, 100 BPD outpatients were selected for the study. The mean age of the participant was 25 years.

Results

It was found that perceived social support (family, friends, and significant others) plays a vital role in the wellbeing of these participants. The correlation between the two is positive as well as statistically significant. This means higher the support these patients experience from their relatives, the better is their social wellbeing.

Conclusions

This study has practical implications for counselors, clinical psychologists, and psychiatrists working in the field.

Evaluation of a skills-based peer-led art therapy online-group for people with emotion dysregulation

OBJECTIVE

We developed and piloted a novel art-based online skills program led by a peer mental health professional with lived experience of complex mental health, including Borderline Personality Disorder (BPD). Key challenges of living with BPD and emotion dysregulation were addressed through artmaking informed by a dialectical framework and skills, to evaluate acceptability and efficacy.

METHOD

A structured, manualised 2-hour weekly arts-based skills program was piloted for people with BPD over 18 weeks. Evaluation included both quantitative and qualitative measures at commencement and completion.

RESULTS

Thirty-eight participants enrolled in the program (89.5% identified she/her pronouns, average age 33.6 years), and 31 completed (82% retention). Multilevel modelling analysis of the primary outcome variable Difficulties in Emotion Regulation Scale (DERS) demonstrated a large improvement over time (effect size Cohen's d = 1.77). Qualitative thematic analysis found participants had improved capacity to regulate emotions and tolerate distress, improved connection with others, enhanced understanding of the self, and higher hope for living well. We found that artmaking facilitated processes and helped the expression of difficult emotions, symbolise challenging relationships, and facilitate greater self-understanding. Participants reported high levels of satisfaction, and 77.4% reported that the program had increased wellbeing.

CONCLUSION

This novel artmaking program for emotion dysregulation and BPD was acceptable and potentially effective. Peer facilitation using arts-based skills is a modality of therapy for further investigation.

Chronic feelings of emptiness in a large undergraduate sample: Starting to fill the void

Chronic emptiness in borderline personality disorder (BPD) has received little empirical attention. We sought to examine basic properties of a single chronic emptiness item, including prevalence, reliability, validity, the relation of the emptiness item to other BPD criteria, and measures of personality. Undergraduates enrolled in psychology courses over 12 years' time completed the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) (N = 22,217). Subsets of participants completed the International Personality Disorder Examination-Screening Questionnaire (IPDE-SQ) (N = 2732), The Revised NEO Personality Inventory (Anxiety, Angry Hostility, Depression, Positive Emotions [reversed], and Impulsivity facets) (N = 10,506), and the Depression Anxiety Stress Scales (DASS) (N = 1110) as validity indicators; 10.0% of respondents endorsed emptiness. Reliability indices suggested moderate levels of reliability between two emptiness items (r(2730) = 0.61, p < 0.001). Among BPD criteria, emptiness and identity disturbance correlated most strongly (r(22,215) = 0.81, p < 0.001). MSI emptiness was more correlated with depression on the NEO (r(10,504) = 0.43, p < 0.001) and DASS (r(1108) = 0.51, p < 0.001) than other facets of negative affect. Emptiness was more correlated with greater borderline pathology than any other MSI-BPD item (Sample 1, r_tet  = 0.87; Sample 2, r_tet  = 0.86). This criterion warrants further study and attention, especially related to assessment of BPD.

Screening for borderline personality pathology on college campuses

Although borderline symptoms show a normative decline throughout adulthood, severe psychosocial impairment often remains. Identifying personality pathology in college-age students may help prevent "adaptive failure" that can occur during the critical period of development from puberty through the late 20s and thus reduce impairment later in life. The aims of the current study were to estimate the prevalence of borderline personality disorder (BPD) in a diverse college sample, determine which symptoms confer the greatest relative risk of screening positive for BPD and examine the utility of the Personality Inventory for DSM-5 brief form (PID-5-BF) in identifying BPD. Participants were 1456 undergraduate students, and 312 individuals (21.4% of the sample) screened positive for BPD. Chronic feelings of emptiness conferred the greatest relative risk of any symptom; students who endorsed this symptom were 15 times more likely to screen positive for BPD than those who did not. Scales and composite scores of the PID-5-BF demonstrated diagnostic accuracy ranging from sufficient to excellent. The current study contributes to literature concerning best practices in screening for personality pathology in young adults. Results suggest that chronic feelings of emptiness are significant for detecting at-risk students and implications for the use of the PID-5-BF are discussed.

Development and Initial Validation of the Multidimensional Sense of Emptiness Scale

The present study describes the development and initial validation of the Multidimensional Sense of Emptiness Scale, a measure based on a theoretically and empirically grounded conceptualization of emptiness. In the first sample ( n = 541), an exploratory factor analysis yielded three factors, Sense of Inner Emptiness, Sense of Absence of Relatedness, and Sense of Meaninglessness, explaining 82.8% of the variance with 13 items. In an additional sample ( n = 212), a confirmatory factor analysis supported this three-factorial solution's stability. Furthermore, all subscales were significantly related to a single, second-order factor. In the total sample ( N = 753), subscale and full-scale items offered evidence of satisfactory internal consistency and convergent validity. We discuss study limitations and implications for counseling practice, advocacy, education, training, and research.

Associations between symptoms of borderline personality disorder and suicidality in inpatient adolescents: The significance of identity disturbance

Several studies report that borderline personality disorder (BPD) is a risk factor for suicidality in adults. However, this issue requires further research in adolescents, as it is not clear which individual BPD symptoms are significant correlates of suicidality in this age group. The main aim of the current study was to test which symptoms of BPD are associated with suicidality in adolescent inpatients, even when controlling for age, gender, and depressive symptoms. Inpatient adolescents (N = 339) aged 12-17 years completed the Childhood Interview for DSM-IV Borderline Personality Disorder, the Beck Depression Inventory-II, the Modified Scale for Suicidal Ideation, and reported their number of lifetime suicide attempts. Multivariable regression analyses showed that, after controlling for confounding variables, overall BPD symptom severity was positively related to suicidal ideation and suicide attempts. Of the individual BPD symptoms, identity disturbance, chronic emptiness, avoid abandonment, and transient paranoia were the most robust correlates of suicidal ideation intensity, and only identity disturbance was associated with the number of lifetime suicide attempts. To assess the risk of suicidality in youth, it is essential to assess for BPD symptoms; it is important to focus on adolescents' subjective feelings to assess the severity of identity disturbance and chronic emptiness.

Affective Instability and Emotion Dysregulation as a Social Impairment

Borderline personality disorder is a complex psychopathological phenomenon. It is usually thought to consist in a vast instability of different aspects that are central to our experience of the world, and to manifest as “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity” [American Psychiatric Association (APA), 2013, p. 663]. Typically, of the instability triad—instability in (1) self, (2) affect and emotion, and (3) interpersonal relationships—only the first two are described, examined, and conceptualized from an experiential point of view. In this context, disorders of self have often motivated analyses of self-experience and the sense of self, affective disorders have been frequently considered in the light of emotional experience and its phenomenological structure. Patterns in the phenomenology of social experience have found comparatively little traction when it comes to the conceptualization of the interpersonal disturbances in borderline. In this paper, I argue that interpersonal instability in borderline consists in much more than fragile and shifting relationships but, most importantly, also involves certain styles in experiencing others. These styles, I suggest, may play an explanatory role for the borderline-typical patterns of interpersonal turmoil and so deserve more attention. To better describe and understand these styles, I explore the phenomenological structure of borderline affective instability and discuss the implications it might have for how a person experiences and relates to other people. Considering core aspects of borderline affective instability, such as alexithymia, emotional contagion, emotion dysregulation, and chronic emptiness, I propose borderline can be interpreted as a disturbance of interaffective exchange, which gives rise to certain ways of experiencing others that imply a social impairment.

The experience of loneliness among people with a "personality disorder" diagnosis or traits: a qualitative meta-synthesis

BACKGROUND

Loneliness is prevalent among people with a "personality disorder" diagnosis or who have related personality traits, but the experience of loneliness among people with "personality disorder" diagnoses/traits has not been well described. A qualitative approach has potential to help understand the experience of loneliness among people with "personality disorder" diagnoses/traits, and to develop interventions that promote recovery. We therefore aimed to synthesise the qualitative literature relevant to this topic.

METHOD

We conducted a meta-synthesis of qualitative studies exploring the subjective experience of loneliness as reported by people with "personality disorder" diagnoses/traits. We searched four databases using pre-formulated search terms, selected eligible articles, appraised the quality of each, and analyzed data from eligible studies using thematic synthesis.

RESULT

We identified 39 articles that described the experience of loneliness in people with "personality disorder" diagnoses/traits. From extracted data, we identified seven themes: (1) disconnection and emptiness: a "haunting alienation", (2) alienation arising from childhood experiences, (3) thwarted desire for closeness and connection, (4) paradox: for both closeness and distance, (5) experiences of existential loneliness, (6) recovery, embedded in a social world, and (7) group therapy: a setback. Our results suggest that for our sample early alienating and traumatic experiences may pave the way for experiences of loneliness, which further exacerbate "personality disorder" symptoms and distress.

CONCLUSION

Despite describing a need to belong and efforts to cope with unmet social needs, people with "personality disorder" diagnoses/traits (particularly "emotionally unstable personality disorder") report experiencing an intense disconnection from other people. This seems rooted in early adversities, reinforced by later traumatic experiences. Given the apparent salience of loneliness to people with "personality disorder" diagnoses/traits, interventions focused on helping people connect with others, which may include both psychological and social components, have potential to be beneficial in reducing loneliness and promoting recovery.

The factor structure of the Zanarini Rating Scale for Borderline Personality Disorder: Exploratory Structural Equation Modelling and measurement invariance over time

OBJECTIVES

There is a lack of independent longitudinal evidence on the factor structure and validity of the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD). This study aimed to investigate the dimensionality of ZAN-BPD and its conceptual consistency over time.

METHODS

Adult BPD participants (n = 276) were recruited for a multicentre, two-arm randomised clinical trial with ZAN-BPD measured at baseline and follow up at 12, 24 and 52 weeks. The construct and stability of the ZAN-BPD across 52 weeks was examined through a measurement equivalence/invariance procedure via Exploratory Structural Equation Modelling.

RESULTS

Factor analysis results showed that the ZAN-BPD had a bi-2 factor structure that was stable over 52 weeks with a general factor and two specific factors. Factor loadings for eight of the nine items were greater for the general factor than the two specific factors. Factor 1 contrasts externalising distress with internalising distress. Factor 2 contrasts depression and self-destruction with interpersonal anxiety and conflict.

CONCLUSION

ZAN-BPD is a conceptually and empirically valid measure of total BPD symptom severity in BPD patients over time suitable for use in clinical trials. Two factors related to the expression of distress and self-harm may be utilised as possible predictors of outcome.

Understanding chronic feelings of emptiness in borderline personality disorder: a qualitative study

BACKGROUND

Chronic feelings of emptiness are significant in the lives of people with Borderline Personality Disorder (BPD). Feelings of emptiness have been linked to impulsivity, self-harm, suicidal behaviour and impaired psychosocial function. This study aimed to understand the experience of chronic emptiness, the cognitions, emotions and behaviours linked to emptiness, and clarify the differences between chronic emptiness and hopelessness, loneliness and depression.

METHODS

This study interviewed people (n = 15) with BPD and used a template analysis qualitative approach to understand their experiences of chronic feelings of emptiness.

RESULTS

Chronic feelings of emptiness were experienced as a feeling of disconnection from both self and others, and a sense of numbness and nothingness which was frequent and reduced functional capacity. Feelings of purposelessness and unfulfillment were closely associated with emptiness, and most participants experienced emptiness as distressing. Responses to feelings of emptiness varied, with participants largely engaging in either impulsive strategies to tolerate feelings of emptiness or distracting by using adaptive behaviours. Most participants distinguished chronic feelings of emptiness from loneliness, hopelessness, dissociation, and depression.

CONCLUSIONS

Feelings of chronic emptiness are an important and challenging symptom of BPD which require clinical intervention. Strengthening identity, sense of purpose and vocational and relationship functioning may reduce the intensity of emptiness.

Understanding the typical presentation of emptiness: a study of lived-experience

BACKGROUND

Persistent feelings of emptiness, while poorly understood, characterise a range of mental health difficulties.

AIMS

To investigate the meaning of emptiness from the perspective of those with lived experience.

METHOD

240 participants detailed their experiences of emptiness in a survey. Inductive thematic analysis was performed to produce a detailed description of emptiness and a definition of its typical manifestation. In a follow up survey, 178 individuals with lived experience of emptiness rated the accuracy of this definition.

RESULTS

Nine components of emptiness were identified. These were used to produce a definition of the typical manifestation of emptiness, which highlighted a sense of going through life mechanically, purposelessly and numbly, with a psychological and bodily felt inner void, together with a sense of disconnectedness from others, and of not contributing to an unchanged but distant and remote world. Participants in the second survey judged this definition as highly accurate.

CONCLUSIONS

First person accounts of emptiness point to an integrated experience concerning the relationship between the self, others, and the external world more generally. Therefore, emptiness can be conceptualised as an existential feeling; a background orientation structuring the way in which the self relates to the interpersonal and impersonal world.

Association of Borderline Personality Disorder Criteria With Suicide Attempts Among US Adults

IMPORTANCE

Rates of suicide are increasing. Although borderline personality disorder (BPD) and other psychiatric disorders are associated with suicide, there is a dearth of epidemiological research on associations between BPD and suicide attempts (SAs). Delineating the SA risk associated with BPD and its specific criteria in a nationally representative sample of individuals could inform recognition and intervention efforts for SAs.

OBJECTIVE

To examine the association of a BPD diagnosis and specific BPD criteria with SAs in US adults.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed data from the National Epidemiological Survey on Alcohol and Related Conditions-III (NESARC-III), a psychiatric epidemiological survey of noninstitutionalized US adults aged 18 or older conducted from April 2012 to June 2013. Eligible adults were randomly selected from households within census-defined counties or groups of counties. Data were analyzed from December 2020 to January 2021.

MAIN OUTCOMES AND MEASURES

Prevalence of Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) psychiatric and personality disorders, BPD and its specific criteria, SAs, and adverse childhood experiences (ACEs), as assessed by structured diagnostic or clinical interviews; prevalence is expressed as weighted means. Multivariable-adjusted logistic regression was used to compare the risk of lifetime and past-year SAs by BPD diagnosis and by each specific BPD criterion. Analyses were adjusted for demographic and clinical factors, including psychiatric comorbidity, age at BPD onset, and ACEs.

RESULTS

Of 36 309 respondents, 20 442 (56.3%) were women and 52.9% were non-Hispanic White; the mean (SD) age was 45.6 (17.5) years. The prevalence (SE) of lifetime and past-year SAs among participants with a lifetime diagnosis of BPD based on original NESARC-III diagnostic codes was 22.7% (0.8%) (adjusted odds ratio [AOR], 8.40; 95% CI, 7.53-9.37) and 2.1% (0.2%) (AOR, 11.77; 95% CI, 7.86-17.62), respectively. With use of diagnostic codes requiring 5 BPD criteria to meet social-occupational dysfunction, prevalence (SE) of lifetime and past-year SAs was 30.4% (1.1%) (AOR, 9.15; 95% CI, 7.99-10.47) and 3.2% (0.4%) (AOR, 11.42; 95% CI, 7.71-16.91), respectively. After excluding the BPD criterion of self-injurious behavior (to eliminate criterion overlap), the prevalence (SE) of lifetime and past-year SAs was 28.1% (1.1%) (AOR, 7.61; 95% CI, 6.67-8.69) and 3.0% (0.4%) (AOR, 9.83; 95% CI, 6.63-14.55), respectively. In analyses adjusting for sociodemographic variables, psychiatric disorders, age at BPD onset, and ACEs, BPD diagnosis and specific BPD criteria of self-injurious behaviors and chronic feelings of emptiness were significantly associated with increased odds of lifetime SAs (BPD diagnosis: AOR, 2.10; 95% CI, 1.79-2.45; self-injurious behaviors: AOR, 24.28; 95 CI, 16.83-32.03; feelings of emptiness: AOR, 1.58; 95% CI, 1.16-2.14) and past-year SAs (BPD diagnosis: AOR, 11.42; 95% CI, 7.71-16.91; self-injurious behaviors: AOR, 19.32; 95% CI, 5.22-71.58; feelings of emptiness: AOR, 1.99; 95% CI, 1.08-3.66). In analysis with BPD criteria simultaneously entered (excluding self-injurious behavior), chronic feelings of emptiness were significantly associated with increased odds of lifetime SAs (AOR, 1.66; 95% CI, 1.23-2.24) and past-year SAs (AOR, 2.45; 95% CI, 1.18-5.08).

CONCLUSIONS AND RELEVANCE

In a national sample of adults, after adjusting for demographic and clinical variables, a BPD diagnosis and the specific BPD criteria of self-injurious behaviors and chronic emptiness were significantly associated with increased SA risk. Although BPD is a complex heterogeneous diagnosis, the results of this study suggest that the criteria of self-injurious behaviors and chronic feelings of emptiness should be routinely considered in suicide risk assessment.

Boredom in Borderline Personality Disorder: A Lost Criterion Reconsidered

Difficulty with boredom was eliminated from the formal diagnostic criteria for borderline personality disorder (BPD) in 1994 based on significantly limited, unpublished data. However, it is apparent in clinical practice that boredom remains relevant to BPD. This review synthesizes empirical research, with consideration of theoretical accounts, to critically examine the relevance of boredom to BPD. We first briefly review issues in defining and measuring boredom and offer an expanded conceptualization for BPD, which includes the notion of boredom reactivity, before turning to boredom's differentiation from and overlap with feelings of emptiness, with which it was paired prior to its removal from the DSM. We then discuss perspectives on boredom's significance in BPD, briefly touching on its relevance in other personality disorders. We propose a Boredom Cascade Model that articulates how boredom and boredom reactivity interact with identity disturbance and chronic emptiness to create escalating patterns of behavioral dysregulation and make recommendations for research and treatment.