Schizophrenia Bulletin vol. 45 no. 1 pp. 106–113, 2019 doi:10.1093/schbul/sbx183 Advance Access publication January 24, 2018 Identity Disturbance, Feelings of Emptiness, and the Boundaries of the Schizophrenia Spectrum Maja Zandersen*,1 and Josef Parnas1,2 1Mental Health Centre Glostrup, University Hospital of Copenhagen, Broendby, Denmark; 2Center for Subjectivity Research, University of Copenhagen, Copenhagen, Denmark *To whom correspondence should be addressed; Mental Health Centre Glostrup, Broendbyoestervej 160, 2605 Broendby, Denmark; tel: +45-30256818, fax: +45-38645550, e-mail: [email protected] Historical and current research on borderline personality behavior) BPD from all other personality disorders. disorder reveal certain affinities with schizophrenia spec- Unfortunately, these criteria remain insufficiently defined. trum psychopathology. This is also the case for the bord- What is it like to have an “unstable self-image or sense of erline criteria of “identity disturbance” and “feelings self” or to experience “chronic feelings of emptiness”? of emptiness,” which reflect symptomatology frequently Importantly, these symptoms are consistently found in found in schizophrenia and schizotypal personality dis- the classical and recent literature on schizophrenia spec- order. Unfortunately, the diagnostic manuals offer limited trum disorders. insight into the nature of these criteria, including possible The aim of this article is to examine the phenome- deviations and similarities with schizophrenia spectrum nological nature of the concept of identity disturbance symptomatology. In this article, we attempt to clarify the and feelings of emptiness and to clarify their diagnostic concepts of identity disturbance and feelings of emptiness significance with respect to the differential diagnosis with an emphasis on the criteria’s differential diagnostic between BPD and the schizophrenia spectrum. After a significance. Drawing on contemporary philosophy, we historical outline of the criteria, we present a phenome- distinguish between a “narrative” self and a “core” self, nological explication of the concepts of identity and self suggesting that this distinction may assist differential diag- and introduce a distinction between “core” and “narra- nostic efforts and contribute to mark the psychopatholog- tive” selfhood that may be differential diagnostically use- ical boundaries of these disorders. ful. Finally, we present and discuss a clinical case with diverging diagnostic perspectives. Key words: borderline/schizotypal/self-disorders/ core self/narrative self The Vicissitudes of Diagnostic Terms The DSM and ICD diagnostic criteria of identity distur- Introduction bance and feelings of emptiness appear in table 1. While Borderline personality disorder (BPD) became an of- there are no descriptions of the experiential quality of ficial diagnosis in 19801 and its prevalence among psy- feelings of emptiness, identity disturbance is described in chiatric inpatients is now reported to be about 20%.2 terms of uncertainty concerning career choices, values, Concomitantly, there has been a decline in the use of the goals, and friendship patterns. In the DSM-IV,6 the con- hebephrenia (disorganized schizophrenia) diagnosis.3 It is cept of “a sense of self” appears for the first time but is not clear whether such changes in incidence reflect new undefined. Instead, we find this term as part of the defi- patterns of psychopathology or are simply consequences nition of identity in DSM-III (table 1). Noteworthy, this of different diagnostic “popularities.”4 In a review of his- definition links disturbance of identity also to schizo- torical and current psychopathological evidence of BPD, phrenia. DSM-IV and DSM-IV-TR7 have no definitions we have claimed that it is nearly impossible to distin- of “identity” and none of the DSM editions offer a def- guish BPD from the schizophrenia spectrum disorders, inition of the term “self.” The formulation of diagnostic especially schizotypal personality disorder (SPD).5 Two criteria is remarkably poor in ICD-10.8 In the alternative BPD criteria, ie, identity disturbance and chronic feelings model for personality disorders, included in Section III of emptiness, distinguish (together with self-mutilating in DSM-5, “identity” and “self-direction” form a “self © The Author(s) 2018. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected] 106 Table 1. DSM and ICD Descriptions of BPD Identity Disturbance and Feelings of Emptiness DSM-IV, DSM-IV-TR, DSM-III DSM-III-R9 DSM-5 AMPD in DSM-5 Section III ICD-10 Identity criterion ID manifested by uncertainty Marked and persistent ID ID: markedly and persistently Identity: Markedly impoverished, Disturbances in and about several issues relating to manifested by uncertainty unstable self-image or sense of poorly developed, or unstable self- uncertainty about identity, such as self-image, about at least 2 of the self. image, often associated with self-image, aims, and gender identity, longterm goals following: self-image, sexual excessive self-criticism; chronic internal preferences or career choice, friendship orientation, long-term feelings of emptiness; dissociative (including sexual). patterns, values, and loyalties, goals or career choice, type states under stress. eg, “Who am I?”, “I feel like I of friends desired, preferred Self-direction: Instability in goals, am my sister when I am good.” values. aspirations, values, or career plans. Emptiness criterion Chronic feelings of emptiness or [As in DSM-III] Chronic feelings of emptiness [See above] Chronic feelings of boredom emptiness Descriptive Section A profound ID may be A marked and persistent ID There may be an ID The patient’s own manifested by uncertainty about is almost invariably present. characterized by [… see self-image, aims, and several issues relating to identity, This is often pervasive, and criterion above]. There are internal preferences such as self-image, gender is manifested by uncertainty sudden and dramatic shifts in (including sexual) identity, or long-term goals or about several life issues, self-image, characterized by are often unclear values. There may be problems such as self-image, sexual shifting goals, values, and or disturbed. There tolerating being alone, and orientation, long-term vocational aspirations. There are usually chronic chronic feelings of emptiness or goals or career choice, types may be sudden changes in feelings of emptiness. boredom. of friends or lovers to have, opinions and plans about career, or which values to adopt. sexual identity, values, and types The person often experiences of friends. These individuals may this instability of self-image suddenly change from the role as chronic feelings of of a needy supplicant for help emptiness or boredom. to a righteous avenger of past mistreatment. Although they usually have a self-image that is based on being bad or evil, Identity Disturbance,Emptiness,andSchizophrenia individuals with this disorder may at times have feelings that they do not exist at all. Such experiences usually occur in situations in which the individual feels a lack of a meaningful relationship, nurturing, and support. These individuals may show worse performance in unstructured work or school situations. […] Individuals with Borderline Personality Disorder may be troubled by chronic feelings of emptiness […]. Easily bored, they may constantly seek something 107 to do. M. Zandersen & J. Parnas functioning severity dimension,” providing a more elab- orate description of identity disturbance, yet still without any additional clarification of the term “self.” Psychoanalytic Roots of Disturbed Identity and Feelings of Emptiness ICD-10 In the pre-DSM-III literature, the concept of “border- line” was typically considered a variant of schizophrenia.5 Many contributions came from psychoanalysts, describ- ing identity disturbance and feelings of emptiness as re- flecting disturbances at a structural level of the psyche. In their terminology, “structure” may refer both to the overall psychic structures in Freud’s model of the id, ego, and superego but also to single mental structures or pro- cesses such as defensive or cognitive functions. : Experience of oneself as In the most influential article on the subject, Deutsch10 No definition : described a group of patients with what she termed “as esteem and accuracy ofesteem and accuracy self-appraisal; a to regulate, and ability for, capacity ofrange emotional experience. Self AMPD in DSM-5 Section III Identity with clear boundaries between unique, self of and others; stability self- if” personalities, referring to the patient’s readiness to mold oneself according to the surroundings and antici- pating the widely used characteristic of borderline ] patients as having a chameleon-like adaptability to oth- ers.11,12 Deutsch found that her patients were not aware of their “as if” personality. Rather they felt an inner emp- tiness, which they tried to overcome by an exaggerated identification with others. Notably, Deutsch considered No definition in : these patients to belong to the schizophrenia spectrum.