-3175317500Marking Rubric and Feedback

-3175317500Marking Rubric and Feedback

ISNP2211 Research Project 1 Assessment 1 Literature Review

Student name:

Key criteria of this assignment Component Mark / Grade Comment

The narrative literature review provides a coherent and a scientifically critical evaluation of the literature:

The focus of the review is clear

The review has a clear goal, argument, and point of view

Previous findings (minimum 5 papers) are critically evaluated (and not just summarized). Examples of critical evaluation include, but not limited to:

Integrate the previous literature and identify relations, contradictions, gaps, and inconsistencies in findings;

Synthesize the findings in respect of established theoretical models or frameworks;

Discuss correct or incorrect definitions, and operationalization of key concepts in the research area;

Discuss psychometric properties of measures (e.g., validity and reliability);

Evaluate research designs (e.g., randomized control studies vs. pilot studies) and consider threats to internal and external validity;

Attend to statistical and clinical significance of findings across studies, and in particular the magnitude (i.e., effect size) of observed effects across studies where reported, and consider threats to reliability of those observed effects (e.g., confidence interval, sample size).

Evaluate data analyses, particularly in respect of new statistical techniques, advances in statistics (e.g., evolution in meta-analytic aggregation and systematic review methods).

Proposals (such as sensible suggestions for future research) are made for resolving the identified problems. /90 Quality of written work including but not limited to:

Structure

Use of appropriate subheadings

Appropriate use of psychological language

Correct spelling

APA7 format, style, and references /10 Feedback to Students

Assignment grade/mark

Percentage Range Criteria

90 100 Outstanding work of exceptional quality showing clear understanding of subject matter and appreciation of issues; well formulated; arguments sustained; figures and diagrams where relevant; appropriate literature referenced; strong evidence of critical thinking, creative ability and originality; outstanding level of intellectual work. Publishable work as is.

80 89 Excellent work of very high quality showing clear understanding of subject matter and appreciation of issues; well formulated; arguments sustained; figures and diagrams where relevant; appropriate literature referenced; strong evidence of critical thinking, creative ability and originality; excellent level of intellectual work. Publishable work with minor amendments.

75 79 Very good work of acceptable Masters level quality showing strong grasp of subject matter and appreciation of dominant issues though not necessarily of the finer points; arguments clearly developed; relevant literature referenced; evidence of creative ability and solid intellectual work and critical evaluation of the literature.

70 74 Good work of acceptable Masters level quality showing strong grasp of subject matter and appreciation of dominant issues though not necessarily all the points; arguments clearly developed; relevant literature referenced; evidence of creative ability and solid intellectual work and critical evaluation of the literature.

50 69 (fail) Average work of below Masters level expected quality showing a lack of in depth understanding of subject matter with lapses and inadequacies in logic, presentation, or originality. Lack of in-depth critical evaluation of the literature.

< 50 (fail) Work of low quality showing inadequate understanding of subject matter. Clear lapses and inadequacies and clearly identifiable deficiencies in logic or originality. Almost no critical evaluation of the literature.

-3175317500Marking Rubric and Feedback

ISNP2211 Research Project 1 Assessment 1 Literature Review

Student name:

Key criteria of this assignment Component Mark / Grade Comment

The narrative literature review provides a coherent and a scientifically critical evaluation of the literature:

The focus of the review is clear

The review has a clear goal, argument, and point of view

Previous findings (minimum 5 papers) are critically evaluated (and not just summarized). Examples of critical evaluation include, but not limited to:

Integrate the previous literature and identify relations, contradictions, gaps, and inconsistencies in findings;

Synthesize the findings in respect of established theoretical models or frameworks;

Discuss correct or incorrect definitions, and operationalization of key concepts in the research area;

Discuss psychometric properties of measures (e.g., validity and reliability);

Evaluate research designs (e.g., randomized control studies vs. pilot studies) and consider threats to internal and external validity;

Attend to statistical and clinical significance of findings across studies, and in particular the magnitude (i.e., effect size) of observed effects across studies where reported, and consider threats to reliability of those observed effects (e.g., confidence interval, sample size).

Evaluate data analyses, particularly in respect of new statistical techniques, advances in statistics (e.g., evolution in meta-analytic aggregation and systematic review methods).

Proposals (such as sensible suggestions for future research) are made for resolving the identified problems. /90 Quality of written work including but not limited to:

Structure

Use of appropriate subheadings

Appropriate use of psychological language

Correct spelling

APA7 format, style, and references /10 Feedback to Students

Assignment grade/mark

Percentage Range Criteria

90 100 Outstanding work of exceptional quality showing clear understanding of subject matter and appreciation of issues; well formulated; arguments sustained; figures and diagrams where relevant; appropriate literature referenced; strong evidence of critical thinking, creative ability and originality; outstanding level of intellectual work. Publishable work as is.

80 89 Excellent work of very high quality showing clear understanding of subject matter and appreciation of issues; well formulated; arguments sustained; figures and diagrams where relevant; appropriate literature referenced; strong evidence of critical thinking, creative ability and originality; excellent level of intellectual work. Publishable work with minor amendments.

75 79 Very good work of acceptable Masters level quality showing strong grasp of subject matter and appreciation of dominant issues though not necessarily of the finer points; arguments clearly developed; relevant literature referenced; evidence of creative ability and solid intellectual work and critical evaluation of the literature.

70 74 Good work of acceptable Masters level quality showing strong grasp of subject matter and appreciation of dominant issues though not necessarily all the points; arguments clearly developed; relevant literature referenced; evidence of creative ability and solid intellectual work and critical evaluation of the literature.

50 69 (fail) Average work of below Masters level expected quality showing a lack of in depth understanding of subject matter with lapses and inadequacies in logic, presentation, or originality. Lack of in-depth critical evaluation of the literature.

< 50 (fail) Work of low quality showing inadequate understanding of subject matter. Clear lapses and inadequacies and clearly identifiable deficiencies in logic or originality. Almost no critical evaluation of the literature.

Chronic Emptiness: A Critical Analysis of Recent Studies and Theoretical Trends

name student

Institute of Social Neuroscience

ISN2211 Research Project 1

Word Count:

Abstract

Chronic emptiness is one of the criteria for borderline personality disorder and is a symptom of several other psychological disorders. Longitudinal studies show chronic emptiness is enduring and it has been associated with self-harm, suicidality, depression, identity disturbance and impulsivity. Despite its clinical significance across disorders, it has received little empirical attention. Past literature shows significant difficulties defining and measuring chronic emptiness due to its inherently abstract construct. While several theoretical approaches have attempted to explain this phenomenon, there currently remains no united conceptualisation, theory or definition of chronic emptiness. In recent years however, there has been an increase in studies attempting to operationalise the construct, with the development of two new measures. Qualitative studies attempting to capture unique qualities of emptiness have also increased. This recent empirical attention has led to the emergence of a transdiagnostic trend, which suggests that core features of emptiness are the same across disorders. The current review provides a critical analysis of five recent studies on emptiness, by highlighting inconsistencies in findings as well as methodological limitations. This review also argues that the current evidence is insufficient to draw conclusions about emptiness as a transdiagnostic construct.

Chronic Emptiness: A Critical Analysis of Recent Studies and Theoretical Trends

The concept of emptiness has long been the subject of scrutiny for many scholars, theologians, artists and poets (Mitchell, 2000). Within the empirical literature, however, this topic has received little attention (Miller et al., 2020). Of all the DSM-5 criteria, emptiness is one of the least researched symptoms (Ermis-Demirtas et al., 2022) despite its association with numerous disorders including depression (Rhodes et al., 2018), schizophrenia (Zandersen & Parnas, 2019), narcissistic personality disorder (Blasco-Fontecilla et al., 2013) and most notably, borderline personality disorder (BPD; Miller et al., 2020). BPD is a complex mental health condition characterised by unstable relationships, unstable mood, suicidal behaviours, impulsivity, anger, identity disturbance and chronic feelings of emptiness (American Psychiatric Association [APA], 2022). In the general population, global prevalence of BPD is 1.6%, yet patients with BPD account for approximately 20% of psychiatric inpatient services (Skodol et al., 2019). Chronic emptiness has been established as a core feature of BPD, yet it remains the least studied symptom compared to other BPD symptoms (DAgostino et al., 2020). One reason for this lack of attention may be that emptiness is inherently difficult to define, given the construct involves an absence of feeling (Klonsky, 2008). As a result, there currently remains no united conceptualisation, theory or definition of chronic emptiness, both in BPD and across psychopathologies (Miller et al., 2020).

Several theoretical approaches have attempted to explain chronic feelings of emptiness. According to early works, emptiness was described as an inner void, and resulted from an inability to feel, experience and fully connect with oneself, others and the world (Cary, 1972). Psychoanalytic theories later proposed emptiness was the result of lacking a nurturing caregiver, which caused profound identity disturbances characterised by an unstable or conflicted sense of self, or a complete lack of self (Adler & Buie, 1979; Cohen & Sherwood, 1996; Levy, 1984). This link between emptiness and identity disturbance then led to postulations about the defensive role of emptiness as a mechanism against painful emotions caused by having a disturbed identity. The theory suggests emptiness can be brought on consciously or subconsciously, to protect one from regressing into more uncontrollable and unbearable states (LaFarge, 1989). Building on this theory, cognitive behavioural therapists have since characterised emptiness as a maladaptive coping strategy caused by an inability to regulate emotions, which is a core feature of BPD (Beck, et al., 1990; Linehan, 1993). This theory, created by Marsha Linehan, was used to inform the development of her dialectical behavioural therapy, which is now considered the first-line treatment for BPD (Stoffers-Winterling et al., 2012).

Although there have been significant advances in research and treatment for BPD, chronic emptiness remains understudied, despite being integral to the formulation and diagnosis of BPD (APA, 1980). Among the more established literature however, research shows chronic emptiness has profound clinical effects. A study by Zanari et al. (2007) investigated the symptom trajectory of people with BPD over a 10 year period. Findings showed feelings of emptiness were the most enduring, with almost all other BPD symptoms remitting within eight years, while emptiness was still evident after 10 years. Another longitudinal study found that after one year of treatment, feelings of emptiness did not significantly change compared to other more acute BPD symptoms (Meares et al., 2011). These studies suggest emptiness may be a core feature of BPD that is stable and enduring over time. Several empirical analyses have also found a strong link between emptiness and suicidality (Klonsky, 2008). One study using a university sample, showed 67% of participants detailed feelings of emptiness before engaging in self-harming behaviours (Delgado-Gomez, et al., 2012), while another study found emptiness was one of the most commonly reported feelings before and after suicide attempts (Chesley & Loring-McNulty, 2003). Furthermore, compared to other BPD criteria (impulsivity, identity disturbance, affective instability) chronic emptiness is the only symptom that has been associated with all of the following psychosocial morbidities: suicide attempts, hospitalisation, social and work impairments, unemployment, increased psychiatric comorbidities, and global functioning impairment (Ellison et al., 2015). These findings highlight the importance of having a unified conceptualisation of emptiness that is able to provide clinicians with a clear and consistent way of assessing and understanding this symptom.

Thankfully, there has been a slight increase in empirical attention on emptiness in recent years. In 2020, Miller and colleagues published the first systematic review on chronic emptiness in BPD (Miller et al., 2020). Despite significant inconsistencies among definitions, an underlying theme emerged which characterised emptiness as a disconnection from the self and others. Emptiness was also consistently found to be a separate, yet related construct to loneliness, depression and hopelessness. Miller et al. (2020) also found emptiness was highly correlated to identity disturbance, which lends support to the theory suggesting emptiness is a defence mechanism (LaFarge, 1989). Miller et al. (2020) also noted most previous studies on emptiness utilised measures containing only one item to test and quantify emptiness. This was attributed as a core reason for the ongoing confusion in the literature on emptiness.

Since this review by Miller et al. (2020), a handful of studies have attempted to define and operationalise emptiness using various research designs. A notable trend has emerged, conceptualising emptiness as a transdiagnostic construct, since this phenomenon exists across a range of psychopathologies. Consequently, two multi-item, transdiagnostic measures of emptiness have been created for use across disorders (Ermis-Demirtas et al., 2021; Price et al., 2022).

The current study provides a critical analysis of these two new measures, along with three additional studies on emptiness, to highlight inconsistencies among findings regarding the core components of emptiness and its related constructs. This review also highlights similarities among conceptualisations of emptiness to build on existing theories and definitions. Furthermore, this review challenges the emerging notion that emptiness is a transdiagnostic construct by highlighting various study limitations which have led to insufficient evidence to make such conclusions. This review also challenges the recent transdiagnostic trend by highlighting the ways in which emptiness may be qualitatively different in BPD compared to other psychopathologies.

Single Item Measures of Emptiness

An exploratory analysis by Martin and Levy (2021) examined several aspects of chronic emptiness in BPD using a large data set of 22,217 US undergraduate students. The study aimed to provide a foundational understanding of chronic emptiness through examining its associations with other BPD criteria, as well as trait and state level negative affectivity. Two measures were used to achieve this; the MSI-BD (Zanarini et al., 2003) and the IPDE-SQ (Loranger et al., 1997). Both measures are screening tools for BPD containing a single item to analyse chronic emptiness. The MSI-BPD item (Have you chronically felt empty?) and the IPDE-SQ item (I often feel empty inside) are both measured dichotomously using yes/no answers. The researchers found chronic emptiness was most correlated with identity disturbance compared to any other BPD criterion. They also found emptiness was consistently more correlated with state and trait level depression, compared to anxiety, angry hostility and impulsivity. These results support key findings in the review by Miller et al. (2020) showing an association between emptiness and identity disturbance, though many previous studies have found stronger correlations between emptiness and impulsivity compared to emptiness and depression (Miller et al., 2020). Given the correlational nature of this study, however, conclusions cannot be made as to why emptiness may be more related to depression than impulsivity. It is also unclear whether the association between emptiness and identity disturbance is due to emptiness functioning as an underlying defence mechanism against distressing identity related feelings or whether emptiness is the result of a lack of identity in this context.

The use of two single items to measure emptiness also limits the reliability of these correlations given the narrow scope of such items used to measure a difficult to define construct. In this study by Martin and Levy (2021), the convergent validity between the IPDE-SQ and MSI-BPD emptiness items was only adequate, suggesting these two items may be measuring different constructs. This is plausible given the words empty, often, and chronically can be interpreted many different ways. A bereaved participant may be experiencing temporary feelings of emptiness that feel chronic in nature due to their intensity and duration, but are a response to a temporary situation. Similarly, one participant may view monthly feelings of emptiness as occurring often while another may view this as rare. The two items in this study fail to make distinctions between the myriad of experiences and interpretations regarding chronic feelings of emptiness. Therefore participants may be reporting experiences of emptiness completely unrelated to BPD. The use of self-report measures further limits the reliability of the two emptiness items, since participants may have misunderstood items or found them difficult to interpret, which has been a common issue in previous studies on emptiness (Miller et al., 2020).

Although the findings of this study are consistent with the findings of the Miller et al. (2020) review, the measures used to test emptiness are insufficient to draw reliable conclusions about the correlations between emptiness, depression and identity disturbance. As Miller et al. (2020) noted, most previous studies on emptiness in BPD have used single-item measures, which is arguably one of the main reasons for the ongoing confusion within the emptiness literature. Therefore, this study may further add to this confusion rather than contribute to the clarification of emptiness and its related constructs.

Uni and Multidimensional Measures of Emptiness

Recent efforts have been made to create more comprehensive measures of emptiness that can better explain this broad construct. Ermis-Demirtas et al. (2021) have created a multi-dimensional, transdiagnostic measure of emptiness known as the Multidimensional Sense of Emptiness Scale (MSES). The MSES is based on emotional, existential, social and spiritual perspectives of emptiness. This scale was created using a non-clinical sample of 405 university students from a US sample. Four distinct factors of emptiness corresponding to these theoretical perspectives were identified; Sense of Inner Emptiness, Sense of Meaninglessness, Sense of Absence of Relatedness and Sense of Spiritual Emptiness.

The Sense of Absence of Relatedness factor describes a sense of disconnection from community and society and an inability to connect with others and form meaningful relationships. This emptiness factor aligns with the main findings of Miller and colleagues review, which defined emptiness as a sense of disconnection from self and others (Miller et al., 2020). The Inner Sense of Emptiness factor, which describes emptiness as an inner hollowness, is also in line with previous research describing emptiness as a hole or vacuum (Miller et al., 2020). There are, however, two factors of the MSES that are inconsistent with descriptions of emptiness found in the Miller et al. (2020) review, and in previous research on emptiness unrelated to BPD (Rhodes et al., 2018). These factors are the Sense of Meaninglessness factor which describes a lack of purpose and direction in life and the Sense of Spirituality factor, which describes a lack of connection to God or a higher power (Ermis-Demirtas et al., 2021).

One reason these two factors may be inconsistent with previous findings on emptiness is that they appear to be measuring more normative experiences of emptiness, rather than those related to psychopathology. For the Sense of Meaninglessness factor, for example, Ermis-Demirtas et al. (2021) draws on theoretical perspectives from Rollo May (1953) and Victor Frankl (1959) suggesting humans have an inherent will to find meaning in their lives and without it, emptiness results. These existential theorists viewed emptiness as a universal phenomenon, and one of the cardinal concerns of the 20th century. Therefore, the sense of meaninglessness factor may be capturing a normative experience of emptiness rather than a clinical one related to psychopathology. This is evident in the description of emptiness as a lack of purpose or direction in life, which is arguably a common human experience, dependent on ones context and age. Additionally, the Sense of Spirituality factor may also describe a normative experience, since a lack of connection to God is likely another common experience, given the societal shift towards atheism, particularly in the West (Horner & Romano, 2021).

These findings discredit claims that the MSES is a transdiagnostic construct, since this measure may not be capturing clinical experiences of emptiness, both within BPD and across disorders. These findings also highlight a potential discrepancy between the aims of the MSES and its theoretical foundations. Part of the researchers aims were to overcome the limitations of single-item measures by creating a multidimensional measure of emptiness that is able to capture vast elements of the emptiness experience. However, Ermis-Demirtas et al. (2020) also noted the MSES was designed to provide researchers and clinicians with a reliable tool for assessing and diagnosing mental health disorders related to emptiness. Therefore, utilising a measure with constructs designed to test normative experiences of emptiness may provide little clinical utility and may even compromise rapport between clinicians and clients if clients feel they are being asked to answer test items that do not represent their experience of emptiness.

A briefer scale by Price et al. (2022), known as the Subjective Emptiness Scale (SES) has subsequently been developed. The SES was constructed and validated using a US sample of 544 university students with several psychiatric diagnoses, as the researchers wanted to create a transdiagnostic measure of emptiness. Unlike the MSES, the SES is a unidimensional measure of emptiness consisting of five items which aim to describe the core features of emptiness. The SES defines emptiness as a feeling of not being in ones own life, a forced existence, a lack of fulfilment and a profound aloneness (Price et al., 2022).

Two items of the SES appear to align with previous characterisations of emptiness. The item I feel empty inside is consistent with the Inner Sense of Emptiness factor of the MSES and findings of the Miller et al. (2020) review. Additionally, the item I feel absent in my own life appears to be most aligned with the Sense of Absence of Relatedness factor in the MSES, as both describe a feeling of disconnection from ones life and the people in it. These features also align with Miller and colleagues definition of emptiness as a sense of disconnection from self and others (Miller et al., 2020). There is however one item of the SES- I feel all alone in the world, that appears less consistent with previous findings on emptiness. This item suggests loneliness may be a core feature of emptiness, yet one of the clearest findings in past research is that emptiness and loneliness are two separate constructs (Miller et al., 2020). Price et al. (2022) however, provide no further descriptions or details of this SES item, therefore it is difficult to determine whether aloneness is the same as loneliness in this context. Nonetheless, this item highlights a potential discrepancy between the current measures of emptiness.

Another interesting finding in the Price et al. (2022) study is the strong correlation between the SES and a lack of identity. One of the defining symptoms of BPD is identity disturbance, which can include a lack of identity characterised by feelings of not existing (APA, 2022). Of all the psychiatric disorders, this symptom is most closely related to BPD, and to chronic emptiness in BPD. As mentioned above, some theories have suggested emptiness in BPD may function as a defence mechanism to manage the overwhelming distress caused by identity disturbance (LaFarge, 1989). Therefore, the SES may be measuring a particular type of emptiness specific to BPD, rather than an transdiagnostic emptiness. Furthermore, Price et al. (2022) did not collect information relating to specific psychiatric diagnoses. Therefore, it cannot be ruled out that the majority of participants in this sample may have BPD, which further challenges claims of the SES as a transdiagnostic measure.

Qualitative Studies on Emptiness

In an effort to further understand emptiness, some researchers have utilised thematic analyses to better capture the phenomenological experiences of people with chronic emptiness. Miller et al. (2021) interviewed 15 people with BPD about their experience of emptiness and how it relates to their emotions, cognitions and behaviours. They also analysed the differences between chronic emptiness, hopelessness, depression and loneliness. The researchers found chronic emptiness was most often described as a sense of numbness and disconnection from self. It was also described as a disconnection from others, though this was less common. These findings align with the definition of emptiness in the Miller et al. (2020) review, and with the social and emotional emptiness factors of the MSES. Consistent with previous research (Miller et al., 2020), participants also indicated chronic emptiness was separate from loneliness, depression and hopelessness, in that emptiness is an absence of feeling as opposed to the presence of negative feelings (Miller et al., 2021). These findings therefore challenge the aspect of the SES which suggests loneliness is a core feature of emptiness (Price et al., 2022).

Participants also noted chronic emptiness occurred most often when they were distressed or experiencing interpersonal dysfunction. This is one of the few studies to directly measure this element of emptiness, and supports the theory suggesting emptiness may function as a defence mechanism against identity disturbance, since one of the consequences of identity disturbance is interpersonal dysfunction. Therefore, participants may be more likely to engage in feeling empty as a defence against the stress caused by identity disturbance. Indeed, many participants directly spoke to this theory, explaining that they do in fact use emptiness as a coping strategy to tolerate stress (Miller et al., 2021). This supports the argument that emptiness is not a transdiagnostic construct since its function, in this context, is to manage other BPD symptoms, therefore chronic emptiness may be qualitatively different in individuals with BPD.

Another recent thematic analysis by Herron and Sani (2021) surveyed 240 people, both with and without a mental health diagnosis about their experiences of emptiness. They identified nine main components of emptiness. Five related to participants' bodily sense of emptiness described as a hollowness, ache or knot in the chest. This is the first description to include bodily sensations as a key feature of emptiness. There have been previous mentions in past literature (DAgostino et al., 2020), though not to the extent of being a core defining feature. Three other components of emptiness in this study relate to a disconnection from others, and to a lesser extent from oneself (Herron & Sani, 2021). This component is consistent with previous findings, although slightly deviates from the above thematic analysis which found a disconnection to others was more central to the conceptualisation of emptiness than a disconnection to self (Miller et al., 2021). The final component of emptiness was related to a disconnection to the external world as it relates to things and objects. This distinction between various forms of disconnection is another novel finding, and points to another potential inconsistency in key features of emptiness.

Herron and Sani (2021) also asked participants about the frequency of their emptiness experiences. Interestingly, most reported feeling empty either all of the time or very often, which could indicate these components of emptiness are describing a more severe and chronic type, indicative of emptiness in BPD. Although Herron and Sani (2021) used both a clinical and non clinical sample to draw conclusions about emptiness as a transdiagnostic construct, like Price et al. (2022), they failed to collect information relating to specific psychiatric diagnoses. Therefore, it could be that the majority of participants in this sample also have BPD, since the majority of emptiness descriptions matched those typical of a BPD emptiness. This again, challenges the emerging argument that emptiness is a transdiagnostic construct.

While these findings highlight some unique features of emptiness that may be particular to BPD, the use of qualitative analyses limits the generalisability of results. The reliance on participants' ability to describe a construct that has historically been difficult to define, may be a major limiting factor. This may have led to only using participants who were able to successfully communicate their feelings of emptiness, thereby biassing the results. All participants in the Miller et al. (2021) study had received therapy within the previous two years, therefore these individuals may have been more able to describe their feelings of emptiness due to the effects of psychological treatment. One such effect may be a reduction in symptom severity, which could mean these results may largely be descriptions of chronic emptiness as it is experienced by those with milder symptoms. Another limiting factor of qualitative designs is their vulnerability to researcher bias (Roulston & Shelton, 2015). This may be particularly relevant in the Miller et al. (2021) study, as the authors are the same as those of the Miller et al. (2020) review, therefore interpretations of participants' descriptions may be influenced by the researchers' expectations for similar results across both studies.

Summary and Future Directions

In summary, chronic emptiness is a complex psychological symptom that is difficult to describe, understand and define. Despite its importance in BPD and other psychological disorders, it has not received the same empirical attention as other symptoms. The current review provided a critical analysis of five recent papers attempting to define and operationalise emptiness using both quantitative and qualitative study designs consisting of single and multi item measures of emptiness, as well as thematic analyses.

The most consistent results across studies showed emptiness is an inner hollowness and a disconnection from self and others (Ermis-Demirtas et al., 2021; Herron & Sani, 2021; Price et al., 2022; Miller et al., 2021). These findings strengthen similar results of the previous review by Miller et al. (2020), since these studies used in-depth, comprehensive analyses of emptiness compared to the single-item measures of Miller and colleagues review.

There were also a number of inconsistencies among findings in the current review. The SES item (Price et al., 2022) suggesting loneliness as a core feature of emptiness is inconsistent with previous findings in the current review and in previous reviews (Miller et al., 2020; Klonsky, 2008). Other inconsistencies pertain to key findings of Herron and Sanis (2021) study, suggesting somatic sensations as a core component of emptiness. These findings suggest there are still gaps in the literature regarding a unified definition of emptiness, even with the creation of more comprehensive measures.

With respect to emptiness as a transdiagnostic construct, this review highlighted some significant experimental issues which threatens the reliability of this claim. The lack of descriptive statistics on psychiatric diagnoses in the study samples of Price et al. (2022) and Herron and Sani (2021) prevent generalisability of results to other disorders. Moreover, the findings supporting the theory of emptiness as a defence mechanism (Price et al., 2022; Miller et al., 2021) also challenge the transdiagnostic trend, as these results suggest emptiness may be qualitatively different in individuals with BPD.

Future studies should continue to use in-depth analyses to further determine and expand on the current elements of emptiness which are most consistent in the literature. Studies should also continue to clarify the boundaries of emptiness as it relates to other constructs such as loneliness. Further research is also needed to validate the MSES (Ermis-Demirtas et al., 2021) and SES (Price et al., 2022) as a transdiagnostic measure by including samples of people with BPD and other psychiatric disorders. Richer descriptives relating to specific diagnoses must be utilised here. Further developments of measures that are better able to capture variations in emptiness across diagnostic groups may also be clinically useful. Future studies should also explore the role of emptiness as a defence mechanism to clarify whether this construct may be experienced differently in individuals with BPD. Finally, the current findings should also be replicated using more heterogenous samples to increase generalisability of results, since most of the studies in this review utilised university samples.

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