Clinical Handbook of Mindfulness (40 page)

cases, patients tend to react by raising their level of arousal, for example,

seeking promiscuous sexual relationships, dangerous acting out, and alcohol

or substance abuse to the point of no return or bulimic crises.

From a psychodynamic perspective,
Pazzagli and Monti (2000)
for research purposes consider that two of the criteria listed in the DSM-IV for BPD diagnosis, chronic feelings of emptiness and efforts to avoid abandonment, can

be appropriately grouped together in the concepts of “solitude and empti-

ness.” According to the authors, the borderline person functions via osmosis:

He is empty but, at the same time, intolerant of a solitude in which he keeps

looking for objects to fill this inner sense of emptiness. The solitude of the

BPD patient is actually an intolerance of true solitude, the solitude of being

able to be alone. It is a solitude dominated by emptiness: a void in the outside

world, made up of inadequate objects, sporadic, stormy, and superficial rela-

tionships prone to sudden break-ups, and a void in the inner world, always

subject to the threat of rupturing and the loss of limits.

In a research study conducted by
Rogers, Widiger, and Krupp (1995)
aimed at identifying the qualitative differences of depression diagnosed in patients

with BPD and others, the most frequent aspects associated with depression

were found to be self-condemnation, emptiness, abandonment fears, self-

destructiveness, and hopelessness. The authors conclude that the depression

associated with borderline pathology is unique in certain aspects. The impli-

cations of the study outline the importance of considering the phenomeno-

logical aspects of depression, among which is the experience of emptiness,

in the BPD.
Leichsenring (2004)
reports the following in another study: “Clinical observations suggest that depressive experiences in patients with bor-

derline personality disorder have a specific quality. These experiences are

characterized by emptiness and anger (‘angry depression’).” In this study,

this observation was tested empirically.
Westen et al. (1992)
found an interpersonally focused “borderline depression” that was phenomenologically

136

Fabrizio Didonna and Yolanda Rosillo Gonzalez

characterized by emptiness, loneliness, despair, and an unstable negative

affectivity. The quality of the depression may also have consequences for

pharmacotherapy
(Westen et al., 1992,
p. 391). The qualitative experience of depression (e.g., emptiness or anger) may influence a patient’s reaction to

drugs more strongly than the diagnosis (depression).

Narcissistic Personality Disorder

The essential characteristic of NPD is a pervasive picture of grandiosity,

necessity of admiration, and lack of empathy, with onset in early adult age

and present in a variety of contexts (DSM-IV,
APA, 2000).
On the whole, we can say that the authors studying the disorder can be divided into those who

describe some subtypes
(Gabbard, 1989;
Millon, 1999)
and those who lean more to a Horowitz-type interpretation assuming that a subject experiences

a set of multiple distinct mental states. These authors observe how the nar-

cissists oscillate between states of grandiosity, emptiness, shame, anguished

depression, and dysregulated affect with acting-out tendencies
(Horowitz,

1989;
Young & Flanagan, 1998;
Dimaggio et al., 2002).
A substantial agreement exists between the various authors: It is most probable that the narcis-

sist experiences on the whole mental states described in the literature and

that the diagnosed subtype is characterized by the most important and mani-

fest of mental states.
Dimaggio et al. (2002)
have identified in their work four mental states: grandiosity, transition, frightening depression, and devitalized

emptiness. In this state of devitalized emptiness, the emotional experience

is completely shut down; not only are feelings of weakness and fragility “sco-

tomized” (obscured, clouded), but also feelings overall are. Subjects feel cold,

detached, distanced from others and from their own inner experience, and

they perceive an almost unreal world; their body is annoyingly far away and

they are anhedonic. The experience is not at all intensely unpleasant; for

a long time narcissists dwell in this state where they are untouchable, not

subject to self-esteem fluctuations and to the complex, annoying, and incom-

prehensible demands of others.

The fantasy of success and almightiness can fill up mental life even

though these subjects lack the triumphant echoes overwhelming the state

of grandiosity. The aims are mostly inactive. This state largely coincides

with the clinical descriptions of
Modell (1984),
which describes patients as being closed up as if in a “cocoon.” In the long run, this state becomes

ego-dystonic: The subject perceives life as empty and boring, the emotional

coldness touches him, and his need for relationships surfaces unconfessed

(Dimaggio, Petrilli, Fiore, & Mancioppi, 2003).

The sense of emptiness as an important and distinctive experience in NPD

has been indicated by a large number of authors.
Forman (1975)
made a

summary of the characteristics that emerge from the descriptions of
Kohut

(1971).
The most important are low self-esteem, a tendency to have hypocon-driac episodes, and a feeling of emptiness or a deficiency of vital force.

Millon (1996)
gives us the following description of the narcissistic prototype at a biopsychological level in clinical settings: “the narcissistic personality

presents a general indifference, unflappability, and fake tranquility
. . .
except

when his narcissistic confidence is threatened, where brief demonstrations

of anger, shame or feelings of emptiness appear.” Millon identifies rational-

ization as a mechanism of defense in NPD; if the rationalization fails, these

Chapter 8 Mindfulness and Feelings of Emptiness

137

individuals often feel rejected and embarrassed, and experience feelings of

emptiness.
Kernberg (1975)
explains how the experience of emptiness in

narcissists is characterized by the addition of strong feelings of boredom

and restlessness: “Patients with depressive personality and even schizoid

patients, are able to empathize deeply with human feelings and experiences

involving other people, and may feel painfully excluded from and yet able to

empathize with love and emotion involving others
. . .
patients with narcissis-

tic personalities, on the other hand, do not have that capacity for empathiz-

ing with human experience in depth. Their social life, which gives them

opportunities to obtain confirmation in reality or fantasy of their needs to be

admired, and offers them direct instinctual gratifications, may provide them

with an immediate sense of meaningfulness, but this is temporary. When

such gratifications are not forthcoming, their sense of emptiness, restless-

ness and boredom take over. Now their world becomes a prison from which

only new excitement, admiration, or experiences implying control, triumph

or incorporation of supplies, are an escape. Deep emotional reactions to art,

the investment in value systems or in creativity beyond gratification of their

narcissistic aims, is often unavailable and indeed strange to them” (1975,

p. 218)

Schizoid Personality Disorder

The essential characteristics of schizoid personality disorder are a pervasive

condition of detachment from social relations and a restricted range of emo-

tional experiences and expressions in interpersonal contexts. The onset of

this condition is in early adult age, and it is present in a variety of contexts

(DSM-IV,
APA, 2000).

Kernberg
(1975),
as previously indicated, thinks that the experience of

emptiness varies in form, intensity, and etiology in relation to the type of

personality disorder affecting the patient. Even in schizoid disorders, spe-

cific characteristics of emptiness are obviously present. According to the

author, these individuals can experience the emptiness as an inborn qual-

ity that makes them different from others: “in contrast to others, they cannot

feel anything and they may feel guilty because they do not have feelings

of love, hatred, tenderness, longing or mourning which they observe and

understand in other people, but feel they cannot count on to experience

themselves” (1975, p. 215). For these schizoid patients, the experience of

emptiness can be less painful than for the depressed because the contrast

between the periods when they feel empty and those when they would like

to have emotional relations with others is less violent. A feeling of inner fluc-

tuation, of subjective unreality, and the appeasement derived from this same

unreality make the vacuous experience more acceptable to schizoids, allow-

ing them to fill in time with the awareness of external reality opposed to

their subjective experience.

Depression and Emptiness

Many people who come to therapy complain about having a senseless life.

Their words express the idea of deep and anguishing “emptiness” leading

them to wish for death as a liberation from this state. These patients often suf-

fer from depression, and what has been described is only the manifestation

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Fabrizio Didonna and Yolanda Rosillo Gonzalez

of one of the many emotional, cognitive, and physical symptoms marking the

disease.

Maureta Reyes
(2007)
defines this existential emptiness as:

the feeling of a lack of a sense in life, of tediousness, of not knowing the reason

for living, leading to isolation and impoverishment of the relation with family

and society [
. . .
] patients with this problem, usually experience moments of

strong tension and anxiety attacks without a valid reason, they worry about

everything, but nothing seriously, they have lost the motivation and interest for

everything and this makes them think that living is the worst thing that can

happen to them. When this situation is prolonged, becoming more intense, it

can lead to suicide.

This type of experience, described as such, appears more frequently in

certain periods of life, for example, during old age, retirement, or the course

of a terminal illness, or in the so-called empty-nest syndrome when adult

children abandon the family home. In the latter case, women, seeing their

role as mothers ending – their children having little need for them and their

husbands busy at work, spending little time with them – are more prone

to feeling depressive symptoms and a sense of emptiness. Old age, though,

is surely a period where this type of feeling of emptiness becomes more

present. Faced with fears associated with becoming old, such as isolation,

solitude, physical decline, no longer being desired, uselessness, the loss of

every role in society or in the family, and illness, it is easy to imagine how

the lack of one’s own sense of life leads to experiencing emptiness.

The feeling of emptiness in depression is often associated with significant

experiences of loss (see also
Bowlby, 1980),
above all in conjunction with a first depressive episode (see also Chapter 12). In some cases, the feeling of

emptiness is connected not only to what is no longer there, but also to what

will no longer be there in the future.

In the following case example, a 41-year-old depressed patient describes

her deep sense of emptiness derived from the loss of her 15-year-old son who

died tragically in a car accident:

I would never have thought that, from one day to another, life could

change so violently and destructively. With N’s death, I find myself having

to reinvent everything, fighting against this harsh reality, with all its emo-

tions and feelings. It is unthinkable that he is no longer here with me and

that he has left this immense emptiness just in this moment: a life yet to

start, come to a sudden end by such an unfair destiny
.

The pain is so great that with its presence, it is actually physical every

time I think of the things N. liked and loved to spend his time on, his

determination and will to live. It’s like suddenly opening a door without

expecting to find someone there: an icy wave, a shock which rises up from

my feet and leaves me momentarily incredulous that all this belongs to

me. A great weakness is left behind and a loss of feeling pervades my

arms and hands. I get a tingling which becomes all one with a pain in

my stomach as if it were knotted. These are very hard moments that make

me realize that I’ll never have him near me again. This great emptiness

that I perceive projects itself not so much in my past memories which are

alive, but based on the fact that I will never experience some situations or

Chapter 8 Mindfulness and Feelings of Emptiness