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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.

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.

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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.

To address the gap in the research, this research aims to capture the phenomenological experiences of chronic emptiness for individuals with BPD. Specifically, the research aims to identify common experiences of chronic feelings of emptiness for people with BPD, understand cognitions, emotions and behaviours linked to emptiness, and clarify the differences between chronic emptiness and related experiences.

The four participants who endorsed the highest severity (most or all of the time) of chronic emptiness were all single, not currently employed and had an average age of 50 years. The four participants who endorsed the least severe emptiness in the past fortnight were all in a relationship or married, and were in part- or full-time employment or caring for others. The average age of these participants was 31 years.

Participants discussed a wide range of ways in which they try to prevent chronic emptiness from occurring, and methods for coping and alleviating chronic emptiness. Typically, similar strategies were employed to prevent, cope with, and alleviate chronic emptiness.

Feelings of chronic emptiness in this sample seemed to stem from a disconnection from self and others. In relation to a disconnected sense of self, participants noted that chronic emptiness arose from feeling like they had no identity, that their identity was unstable and difficulties with self-direction, values and goals. This supports previous theoretical work that considers emptiness in part as a reflection of disturbed self-representations [6, 28, 29]. Furthermore, participants reported that a disconnection from self and an associated feeling of emptiness often led to feelings and cognitions of purposelessness in life.

For most participants, chronic emptiness was experienced as distressing and they attempted to prevent, tolerate or alleviate chronic feelings of emptiness. Participants who had not previously considered the link between emptiness and impulsive behaviours prior to participation in this research often attempted to relieve emptiness by engaging in maladaptive and impulsive coping strategies. This supports previous literature that hypothesised emptiness feels intolerable and people engage in impulsive behaviours to generate alternate affects to emptiness [10, 13, 15]. It may also indicate maladaptive responses could arise from difficulties with identifying emotions and their behavioural sequalae. On the other hand, participants who had already identified a link between emptiness and urges to engage in impulsive behaviour discussed noticing feelings of chronic emptiness and choosing to engage in adaptive behaviours to alleviate or tolerate the feeling. Perhaps, engaging in a form of activity aids in quelling or distracting from the emotional and cognitive load of emptiness and those that were more aware of the experience were able to make an active choice on how to respond. This is a novel finding with clinical relevance. Firstly, clinicians may benefit from looking beyond impulsive or self-destructive behaviours and exploring what experience spurs these behaviours. This may increase awareness, reflective capacity and mindfulness of emotion. Secondly, when clients are experiencing difficulty with chronic feelings of emptiness, clinicians may work collaboratively with clients to determine adaptive coping strategies. Specifically, it seems that engagement in vocation and relationships may serve as both a protective buffer against disconnection from self and others and subsequent emptiness. While strategies including behavioural activation may be helpful in replacing maladaptive strategies for coping with chronic emptiness, most participants noted that they are a short-term strategy. Participants were unsure what helps emptiness to resolve in the long-term, which may reflect both the chronic nature of emptiness and the lack of treatment targeted towards the experience.

While most participants reported they found feelings of emptiness distressing, some participants noted chronic emptiness could be brought on intentionally to tolerate distress, in an attempt to regulate intense emotion and prevent behavioural dyscontrol. This may be important in clinical practice for clinicians to discern how individuals relate to feelings of chronic emptiness and the distress associated with emptiness.

Most participants differentiated between feelings of chronic emptiness and associated constructs like loneliness, hopelessness and dissociation. The distinguishing factor was that chronic emptiness is an absence of emotion compared to other experiences which have a visceral feeling. However, participants noted that emptiness and loneliness often coincide which is unsurprising given that the experience of loneliness for people with BPD is prevalent and persistent [34]. It is possible that the disconnection from others experienced as chronic emptiness may be exacerbated by feelings of loneliness.

The majority of participants indicated their experience of chronic emptiness could be differentiated from the experiences of depression. While a meta-analysis reported support for a BPD-specific depression characterised by anger, hostility and self-criticism, there were no studies that compared feelings of emptiness in BPD and depressive disorders [17]. This study has shown that from a qualitative perspective, chronic emptiness and depression may be related but are separate experiences for this sample of people with BPD.

Future studies could investigate the role of social cognition deficits in identity and chronic emptiness and explore emotion awareness and the impact on behaviour in BPD. Also, more knowledge is required to better understand the differences between people with BPD who actively try to inhibit their emotions by creating a feeling of emptiness, versus those for whom chronic emptiness is unavoidable and distressing. Similarly, future research could further investigate the similarities, differences and relationship between dissociation and chronic feelings of emptiness. While participants in this study provided a range of short-term measures to prevent, tolerate and alleviate chronic feelings of emptiness, the field may benefit from studies trying to understand how to reduce the severity and impact of chronic emptiness over the longer-term for people with BPD. As chronic emptiness is one of the last symptoms of BPD to resolve [16], research into interventions for chronic emptiness is warranted.

This novel study found that for people with BPD, chronic emptiness is experienced as a sense of nothingness and numbness that reflects a feeling of disconnection from both self and others. It is associated with feelings of unfulfillment and purposelessness. Chronic emptiness is a frequent experience that significantly limits the functional capacity of people with BPD and is distinguishable from loneliness, hopelessness, dissociation, and depression. It is possible that reduction in identity disturbance and improved vocational and relationship functioning may reduce the intensity of chronic emptiness. It is difficult to alleviate, however there are a range of strategies people with BPD engage in to prevent, tolerate and alleviate chronic emptiness which may be harnessed for future interventions.

Background: Empty nose syndrome (ENS) is characterized by the paradoxical perception of nasal obstruction despite patent sinonasal anatomy after surgery. We investigated the relationship between ENS, and anxiety, depression, obsessive-compulsive disorder, and somatic symptom disorder (SSD) compared to individuals with chronic rhinitis (CR) and chronic rhinosinusitis (CRS).

More severe cases of intracranial hypertension may cause significant compression of the pituitary gland, eventually leading to empty sella (ES) on brain magnetic resonance imaging (MRI). ES involves the herniation of the subarachnoid space within the sella turcica, associated with an elongated pituitary stalk and a flattening of the pituitary gland to less than 2 mm. Partial ES is diagnosed when < 50% of the sella is filled with cerebrospinal fluid, and total ES is diagnosed when >50% is filled with cerebrospinal fluid.

According to De Simone et al,99 increased intracranial pressure is likely involved in the progression of migraine in most patients diagnosed with unresponsive chronic migraine. Indeed, in unresponsive migraine patients, lumbar puncture with cerebrospinal fluid withdrawal resulted in sustained remission of chronic migraine pain in 77%.99

Borderline personality disorder (BPD) is a complex mental disorder characterised by a pervasive instability of self-concept, emotions, and behaviour [2]. Globally, lifetime prevalence of BPD is estimated at approximately 6% [3], but individuals with BPD can account for up to 20.5% of emergency department presentations and 26.6% of inpatient psychological services [4]. Within personality disorder research, the landscape of formulation and diagnosis is evolving, and there is a need to research features of BPD which are important in both traditional categorical and emerging dimensional approaches [5]. Current diagnosis for BPD involves identifying a minimum five of nine possible criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [2]. One criterion is labelled chronic feelings of emptiness. This symptom remains in the alternative diagnostic model for BPD in DSM-5, where it is associated with identity disturbance. e24fc04721