The phenomenon of “emptiness” in modern psychiatry

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The appearance of new psychopathological symptoms in psychiatry is rare and unusual. Most clinical phenomena have remained unchanged for decades. The same applies to patients’ complaints, which tend to not exhibit considerable changes. The only phenomena that have changed in psychiatry are the designations (names) of mental illnesses or mental disorders as reflected in classification categories.

Therefore, the phenomenon of a “feeling of emptiness” is unique because despite the increase in reports of such a condition, it is not mentioned in psychiatric thesauri, dictionaries of psychiatric terms, and lists of symptoms [1–4]. There is no indication of the phenomenon of emptiness in the map of subjective experiences (feelings) [5].

The phenomenon has been mentioned only in Encyclopedia Britannica, where it is described indirectly using an analogy. Emptiness is defined as “a feeling of universal boredom, social alienation, nihilism and apathy accompanying dysthymia, depression, loneliness, anhedonia, despair, and other emotional disorders within the framework of schizoid and schizotypal personality disorders, post-traumatic stress disorder, attention deficit hyperactivity disorder, and borderline personality disorder (BPD)” [6]. That is, emptiness is simultaneously recognized as a feeling, a social phenomenon, a worldview, and a decrease in volitional activity, which indicates its psychopathological origin. However, it has also been posited that “the feeling of emptiness may be a part of the natural process of experiencing grief resulting from the death of a loved one or other significant changes”.

Similarly, D’Agostino et al. [7] describe the “feeling of emptiness” as “a complex negative emotional state that different people experience in different ways, with the inclusion of a physical (bodily) component, a component of loneliness (social distancing), and a component of a deep sense of lack of self-actualization or lack of purpose”. The authors claim that the “feelings of emptiness are related to and, to some extent, overlap with dysphoria, boredom, loneliness, and torpor”.

Klonsky [8] opines that it is difficult for clinicians to give a verbal description of “emptiness” because there are few empirical studies on the phenomenon. It is slightly associated with boredom and closely associated with a sense of hopelessness, loneliness, and isolation; it is a significant predictor of depression and suicidal thoughts but not anxiety or suicidal attempts.

Clinical observations indicate that the phenomenon of emptiness differs from other well-known psychopathological symptoms, such as frustration, longing, boredom, and apathy. Below, patients describe their own mental suffering.

Yakov, a 17-year-old patient, states: “Most of all, I am tormented by a feeling of emptiness, benightedness, floating in waves. It is extremely bothersome…it makes it difficult to live. Moreover, this feeling is not connected with any life problems — it arises from nowhere and goes nowhere. Interestingly, this feeling of emptiness can be combined with a feeling of overwhelm. All this is accompanied by a terrible overexcitation and a kind of panic attack. I don’t know how to explain it, but this is an extremely unusual condition. It’s definitely not depression. The only way for me to deal with emptiness is to hurt myself — I cut my hands until they bleed”.

Matvey, an 18-year-old patient, states: “Emptiness in the eyes, emptiness in the soul, emptiness all around. A hopeless, gaping feeling of emptiness. It’s got deep under my skin, [just] sitting there, absolutely not leaving. It accompanies me in the woods, in a room, in a crowded place. You could say that I myself have become a void. But at the same time, there is no desire to leave this life”.

The most complete (almost scientific) analysis of the phenomenon of emptiness was made by an anonymous patient–blogger [9]. From her perspective, the state of emptiness is a state between strong emotions, “which seems to be nothing because (figuratively) it is not filled with the blizzards and storms of winter or the intense heat of the summer sun. The feeling of emptiness is not identical to the concept of ‘senselessness’ because an empty glass may not contain liquid, but it is still full of air”.

The author identified the two most important parameters of the feeling of emptiness: a “feeling of being cut off” and an “intensity of craving”. The former is described as a lack of access to one’s own emotions, that is, “the inability to feel them even when aware of their presence” and “the conviction that they seem to belong to someone else”. The latter is described as follows: “Although strong emotions can be unbearably painful, the patient craves for such intensity. It’s like a drug that an addict can’t get enough of, and the slightest taste of it makes them desperate for it even more. At the same time, there is a paradoxical fear of its absence. The feeling of emptiness doesn’t mean feeling nothing. It means being aware of a gaping hole, but without necessarily knowing what is missing. It means a striving to be filled, but not necessarily knowing with what” [9].

Thus, based on patients’ narratives, it is possible to identify the distinctive features of the feeling of emptiness and distinguish it from an outwardly similar phenomenon — the “feeling of a stone in one’s chest,” which often accompanies the depressive syndrome. Patients themselves recognize the listed mental states as different in essence, localization, specifics of occurrence, and combinations with other emotional experiences.

The “feeling of emptiness” officially appeared in psychiatric classifications only in 1980, when DSM-III-R¹ included emptiness as an important criterion in the diagnosis of BPD [10]. Currently, it is the seventh criterion. Notably, the “feeling of chronic emptiness” is not included in any other category of psychiatric classifications, an indication that it is not recognized as a feature of depression, anxiety disorder, schizophrenia, or bipolar disorder.

The prevalence of the feeling of emptiness is rapidly increasing, which may be because of a marked increase in the diagnosis of BPD. A 20-year analysis of the incidence of BPD shows that this disorder is being diagnosed far more often than it was before (Fig. 1).

Fig. 1. Dynamics of the number of scientific publications on the topic of borderline personality disorder [11].

Researchers hypothesize that the reasons for the increasing frequency of BPD symptoms, such as self-harm (self-injury), self-identity disorder, and feelings of emptiness, are related to changing social traditions in a postmodern society [12]. In the article “Children with Borderline Disorder: Sons of Postmodernism?” [13], the author, following the ideas of Bauman [14], notes that postmodernism has established the narcissistic pattern as dominant and fundamental. In the postmodern society, mass media encourages immediate satisfaction of desires, specifically “the possession of unique objects and exclusive locations,” which allow adults to continue to behave like a child, experience a “mourning for a lost childhood” and resist the restrictions imposed by reality [13, 14].

According to Elsner et al. [15], the feeling of emptiness allows the differentiation of BPD from other mental disorders, such as major depressive disorder.

In this regard, there is a marked decrease in the tolerance of mental suffering or the threshold of “mental sensitivity” and a desire to avoid even minimal emotional discomfort in postmodern reality [16-21].

The concept of narrative identity presupposes the continuity of one’s past, present, and future [22]. This concept is based on a person’s ability to integrate conflicting aspects of their personality into a consistent, comprehensive sense of themselves. In “mature” neurotic disorders, this happens at the expense of the suppression of important desires and opportunities for personal development.

Patients with BPD are unable to form a consistent self-image. Instead, they adopt a postmodern position in their lives, switching from one present to another and completely identifying with their whatever is their current state of affect. Instead of suppression, their means of protection involves a temporary splitting of the self by excluding the past and the future as dimensions of object constancy, attachment, obligations, responsibility, and guilt. The temporal fragmentation of identity eliminates the need to tolerate the ambiguity and uncertainty of interpersonal relationships. The price is a chronic feeling of inner emptiness caused by the inability to integrate the past and the future into the present and, thus, establish a holistic sense of identity [22].

BPD’s example shows how behavioral disorders are closely related to social changes, especially those caused by urbanization and industrialization and their impact on people’s lives and identity [23]. It is believed that emptiness is a protective shield, which safeguards an individual from their inner world of emotional confusion and tension.

An analysis of the correlation between mental emptiness and other symptoms shows that emptiness is more strongly correlated with identity disorder and all other diagnostic criteria of BPD than with any other indicator of borderline pathology [24]. Studies show that there is a strong connection between mental emptiness and suicidal thoughts rather than suicidal tendencies [25], which indirectly confirms the link between emptiness and self-harm. Although some studies note that emptiness is the second most common (25%) cause of suicide [26], greater perception of emptiness predicts a higher initial urge to commit suicide but not the initial urge to self-harm [27].

As the feeling of emptiness is often associated with emotional coldness, suicidal activity, and apathy, it is useful to determine the correlation between emptiness and low empathy (Fig. 2). However, this hypothesis has not yet been confirmed with empirical evidence. Salgado et al. [29] find that empathy manifests itself in different ways in BPD and is not always low. The results of a systematic review involving 45 studies from 2000 to 2019 show that 36 studies showed a lack of empathy, 8 showed an increase in empathy, and 6 showed no significant difference between patients with BPD and healthy people in the control group.

Fig. 2. Model of the relationship between feelings of emptiness and suicidal behavior [28].

The question of the possible existence of the so-called vital void is discussed separately. Vitality is the spark of life, the amount of energy, life tone, and enthusiasm in a person [30]. “Vital shift” or “protopathic change in the actual field of experience” reflects a regression to the phylogenetic and ontogenetic archaic level of response. The clinical manifestations of vitality are the physical experience of a dominant affect, the appearance of a feeling of general bodily change, inhibition of drives, and hyperactivity. Patients clearly distinguish them from manifestations of bodily discomfort caused by diseases of internal organs. The characteristic of vitality usually extends to the concepts of longing, asthenia, anxiety, and depersonalization. Within the framework of this analysis, the question of the possibility of the existence of a “vital void” should be raised.

The specifics of the phenomenon of emptiness can be traced using patients’ experiences shared on social networks. For example, A states: “There is a huge energy raging in me right now, and I just want to throw it out but I don’t know how. At the same time, I am tormented by the terrifying feeling of emptiness that is so characteristic of patients with BPD. Yes, a bit contradictory, energy and emptiness, but that’s just the way it is..”. B states: “It’s familiar to me. The energy is so strong it’s like hara-kiri, like an alien inside. And the emptiness. But this energy, is it like anger at the inability to get that human warmth, those emotions that are so lacking? Anger at people for their indifference, anger at the cold world” [31].

Note that the feeling of emptiness is not combined with apathy, lethargy, lack of initiative, passivity, and other “negative symptoms”. On the contrary, emptiness is paradoxically intertwined with anger, dysphoria, violent energy, and the desire to involve others in their experiences. Thus, it is important to distinguish between “emptiness” and “voidness”. In our viewpoint, these states are fundamentally dissimilar (Table 1).

Table 1. Differential diagnostic criteria for “feeling of emptiness”

Let us turn to another characteristic of the feeling of emptiness, namely, the need to seek empathy from others. Many patients add the word “gaping” in their definition of the feeling of emptiness, and this phenomenon acquires a special meaning. To gape means to be revealed, to show, or to discover depth or failure. The “gaping feeling of emptiness” is experienced as an unrequited and deep feeling that needs empathy or a “shake-up”. Emptiness does not appear to be an individual phenomenon but is associated with the presence and ability to share “mental pain” to be understood.

Kenrberg [32] calls this a shift in relations from the subject toward the object. In his opinion, emptiness, in conjunction with the absence of longing, is experienced as deeply frightening and impersonal, but this “does not deny the fact that the unwillingness to be empty speaks of unconscious fantasies related to protective drive, structural conflict in people with a ‘high level’ of personality organization”.

An important characteristic of the feeling of emptiness is a sense of detachment from both self and others, which is different from hopelessness, loneliness, and intolerance of loneliness [33, 34], and the feeling of emptiness that is most strongly correlated with identity disturbance.

Hadson et al. [35] consider “emptiness” to be a multifaceted, transdiagnostic construct, the same as for different diagnoses of mental disorders, except BPD, in which emptiness is more significantly associated with dissociation than in major depressive disorder. The authors identify several characteristics of emptiness: aimlessness, lack of connection, torpor, self-deprecation, lack of identity, lack of motivation, hopelessness, anhedonia, physical suffering, and dissociation.

Let us focus on the last characteristic and compare it with the fact that the BPD has recently been designated as a “new hysteria” [36–43]. Additionally, we find that BPD’s criterion of emptiness, along with dissociative, narcissistic, and histrionic personality disorders, in the DSM-V belongs to Cluster B personality disorders, or the so-called dramatized personality disorders [44, 45], and dramatization is intended for an external effect, i.e., a symptom attributed to dissociation. Thus, complaints of a “chronic feeling of emptiness” in combination with other manifestations of BPD can have the characteristic of a secondary neurotic benefit and be regarded as manipulative in a sense [46–48].

The close relationship between the symptoms of BPD and dissociative symptoms was confirmed by a meta-analysis of 1,900 studies, which covered 15,219 people in 19 diagnostic categories [49]. The results of the meta-analysis show that BPD and post-traumatic stress disorder are mental disorders in which there is a high level of co-occurrence of the studied symptoms (Fig. 3).

Fig. 3. Mean Dissociative Experiences Scale score for each diagnostic group in a meta-analysis of dissociation in mental disorders; БАР — bipolar affective disorder; ОКР — obsessive-compulsive disorder; ПРЛ — borderline personality disorder; ПТСР — post-traumatic stress disorder [49].

Another controversial issue is the question of why BPD is almost never diagnosed in adults and the elderly [7, 50–52], even though suicide risk increases with age, the incidence of depressive and anxiety disorders does not decrease, and the feeling of loneliness becomes common. Given the fact that identity disorder (depersonalization) is a core symptom of BPD, it is most commonly observed in adolescents, and its frequency decreases sharply over the years (Fig. 4). Perhaps that is why BPD with the phenomenon of feeling of emptiness becomes less common with age.

Fig. 4. Frequency of depersonalization in people of different ages [53].

Thus, the analysis of the feeling of emptiness shows that psychopathologically, it should be interpreted as depersonalization [54] and not as depression or anxiety. It is most likely that depersonalization in BPD is related to dissociation mechanisms in which emotional dysregulation and body schema disintegration play a major role [55].

The wide representation of various dissociative symptoms in the clinical picture of BPD, in conjunction with the phenomenon of emptiness, makes it promising to consider BPD and its individual symptoms as a “new hysteria,” which necessitate a more careful analysis of the dissociative foundations of the feeling of emptiness [56].

Additional information

Funding source. The work was conducted and the article was published using the personal funds of the author's team.

Competing interests. The authors declare that there is no potential conflict of interest requiring disclosure in this article.

¹ DSM is the Diagnostic and Statistical Manual of mental disorders.

About the authors

Vladimir D. Mendelevich

Author for correspondence.
Email: mendelevich_vl@mail.ru
ORCID iD: 0000-0002-8476-6083
SPIN-code: 2302-2590

MD, Dr. Sci. (Med.), Prof., Head of Depart.

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2. Fig. 1. Dynamics of the number of scientific publications on the topic of borderline personality disorder [11].

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3. Fig. 2. Model of the relationship between feelings of emptiness and suicidal behavior [28].

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4. Fig. 3. Mean Dissociative Experiences Scale score for each diagnostic group in a meta-analysis of dissociation in mental disorders; БАР — bipolar affective disorder; ОКР — obsessive-compulsive disorder; ПРЛ — borderline personality disorder; ПТСР — post-traumatic stress disorder [49].

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5. Fig. 4. Frequency of depersonalization in people of different ages [53].

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