Guinjoan, Et. Al

Guinjoan, S.M., Ross, D.R., Perinot, L., Maritato, V., Jordá-Fahrer, M., Fahrer, R.D. (2001).
The Use of Transitional Objects in Self-Directed Aggression by Patients with Borderline

Personality Disorder, Anorexia Nervosa, or Bulimia Nervosa. J. Amer. Acad. Psychoanal.,
29:457-467.
(2001). Journal of American Academy of Psychoanalysis, 29:457-467
The Use of Transitional Objects in Self-Directed Aggression by Patients with Borderline Personality
Disorder, Anorexia Nervosa, or Bulimia Nervosa
Salvador M. Guinjoan, M.D., PH.D.* , Donald R. Ross, M.D.** , Lila Perinot, L.C.PSY.* , Vanesa
Maritato, M.D.* , Martha Jordá-Fahrer, M.D.* and Rodolfo D. Fahrer, M.D., PH.D.*
It is well known that there is a significant epidemiologic overlap between borderline personality
disorder (BPD) and eating disorders (ED) (Davis, Claridge, and Cerullo, 1997; Gershuny and Thayer,
1999; Grilo, Levy, Becker, Edell, and McGlashan, 1996; Herzog, Keller, Lavori, Kenny, and Sacks,
1992; Matsunaga et al., 2000; Sansone, Fine, Seuferer, and Bovenzi, 1989; Skodol et al., 1993;
Steiger and Stotland 1996; Yates, Sieleni, Reich, and Brass, 1989). The current understanding is
that they are distinctly separate syndromes that may frequently exist as comorbid conditions in
afflicted patients (American Psychiatric Association, 1994). However, other authors have described
similarities regarding biochemical variables (Verkes, Piji, Meinders, and Van Kempem, 1996),
developmental events (Everill and Waller, 1995), and family dynamics (Waller, 1994) in these
syndromes. An association between borderline personality traits and weight preoccupation has
also been observed in a nonclinical population, and it has been suggested that this link occurs in a
continuum from normalcy to overt pathology (Davis et al., 1997).
—————————————
* Department of Mental Health, Hospital de Clinicas “José de San Martin,” Buenos Aires,
Argentina.
** Division of Education and Residency Training, Sheppard Pratt Health System, Baltimore, MD.
WARNING! This text is printed for personal use of PEPWEB GENERIC. It is copyright to the journal
in which it originally appeared. It is illegal to redistribute it in any form.
- 457 -
Self-directed aggression is a prominent clinical feature of both BPD and ED. Self-mutilation is a
specific diagnostic feature of BPD (American Psychiatric Association, 1994). Patients with ED
frequently cause serious self-harm through self-starvation, repeated self-induced vomiting, and
laxative or diuretic abuse. Severe anorexia nervosa may result in grave pathological fractures,
death from starvation, and other serious medical complications (Becker, Grinspoon, Klibanski, and
Herzog, 1999; Treasure and. Serpell, 1999). Bulimic patients may create esophageal tears from
their vomiting, which makes this self-destructive behavior similar to more “traditional” forms of
self-mutilation that involve bleeding (Szabo, 1993), Furthermore, chronic suicidality and episodes
that represent more direct expressions of self-harm are important complicating factors in the
long-term course of ED (Coker, Vize, Wade, and Cooper, 1993; Dulit, Fyer, Leon, Brodsky, and
Frances, 1994; Favazza, DeRosear, and Conterio, 1989). Favazza and coworkers (1989) were the
first to propose that ED symptoms and other forms of self-harm such as skin cutting and burning
characteristic of BPD share enough essential features to warrant a separate diagnostic category of
“deliberate self-harm syndrome.”
In this article we present and discuss three patients who had prominent self-directed aggression.
One patient suffered with BPD alone, and two met diagnostic criteria for ED with BPD as a
comorbid condition. In each case, the patient made use of a specific physical object to facilitate,
contain, and structure the act or fantasy of self-harm. We demonstrate how these objects served a
transitional function as first described by Winnicott (1953). Specifically, the object served to
connect the patient to an internalized image of her parent of childhood and/or to her therapist as
parent in the transference. This gave specific meanings to the episodes of self-harm, meanings
that could be understood and worked with productively in psychodynamic psychotherapy.
Case I. BPD Without ED
W, a 31-year-old female nurse anesthetist, was admitted to the hospital for persistent suicidal
ideation. Despite the fact that this was her first psychiatric contact, she reported a long history of
depressed mood and self-destructive behaviors, including burning herself on lightbulbs, delicately
cutting her forearms, and attacking her knee joints with a hammer. She stabilized in the hospital,
returned to work, and began insight-oriented psychodynamic psychotherapy twice weekly. During
the therapy, she struggled with issues of dependency and rage toward
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the therapist, especially around scheduled time away (weekends and especially vacations,
regardless of whether they were initiated by either therapist or patient). At the time of these
separations, she became more despondent and suicidal. It gradually became clear that she could
not keep the image of the therapist in mind while he was away except as a vague condemning
visage that looked down upon her with disgust and disapproval. This image blended with the
image of the patient's angry mother at times. The therapist suggested she call his answering
machine to hear his recorded voice during breaks, but this did not seem to relieve her separation
dysphoria.
In the second year of therapy, W began to steal drugs from the medication supply at work and
stockpile them with the expressed intent of using them to commit suicide when she “felt bad
enough.” She gathered digitalis, potassium, and insulin along with syringes, needles, and tubing.
When she reported this to her therapist, he became alarmed and insisted that she turn them over
to him at the next session in order to assure her safety. She did so with great reluctance and
anger. Over the next six months, she stole supplies three more times. Each time, she eventually
confessed this to her therapist, and he coerced her to turn them over to him.
After reporting this case in supervision, the therapist was advised to explore the patient's
associations around the various vials of poisonous medications. This proved quite useful. W would
think about her therapist when “planning” her suicide. Sometimes this would take up hours of an
otherwise miserable and lonely day. She especially found it helpful on long weekends, when she
knew she could not see her therapist. Then she would fantasize about the suicide while holding
one of the vials in her hand. She would imagine the grief of her therapist learning of her death or
even finding her body. She also associated the vials of medication to her work as a nurse. It was
only as a nurse that she felt valuable, worthwhile, and secure in her sense of self. The therapist
now suggested that she think of him talking to her—picture his face and voice—while holding the
vial of potassium. She found she could evoke and hold this image much more easily than had been
possible before. With the potassium vial in hand, the image was comforting and clear. The suicide
fantasy quickly dropped out of the picture.
Over the next year, W used a vial of potassium chloride as a transitional object to comfort herself
and to help her conjure up the image of her therapist when she was angry at him or when he was
away. In this way, she reliably could call to mind his concern about her safety, as he had expressed
it in such clear and unambivalent terms when demanding she turn over the vials to him in the
past. Now she had an image of
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herself as cared for by him. After understanding this and working for many months in therapy with
her feelings about being abandoned (by therapist and parents), she spontaneously gave up the
medication vials. By then she was able to get the same psychological benefit from using the
therapist's telephone answering machine. The patient's suicidality and other self-destructive
behavior faded from the picture as the therapeutic work continued.
Case 2. Anorexia Nervosa with BPD
Y was a 20-year-old single woman, a university student who was not working or attending school
when she began psychodynamic psychotherapy with her current therapist. She reported eating
problems shortly after her menarche, in the form of restrictive anorexia nervosa, which over the
years was interrupted by occasional binges. She had received behavioral treatment in an eating
disorders outpatient clinic for about four years during her adolescence. At the end of her freshman
year at the university, she broke up with a boyfriend she had been dating for several months.
During the ensuing summer vacation, she lost a maternal uncle and cousin in a car accident. These
episodes precipitated a period of worsening symptoms of affective lability, severe restriction of
food with occasional binges, and treatment noncompliance. In the following three months, she
saw four different therapists designated by her health insurance company in an effort to bring her
symptoms under some control. Eventually, she was admitted to a psychiatric inpatient clinic for
three weeks due to concerns with her suicide potential, lack of response to treatment, and
noncompliance with a variety of medications that had been tried in quick succession (three
antidepressants, lithium, carbamazepine, valproate, and two antipsychotics in different
combinations). During her inpatient stay, she used a metal ring she was wearing to make
numerous superficial cuts up and down her entire left upper limb.
In regards to her eating symptoms during this period, Y alternated periods of serious food
restriction with brief binges. Her weight oscillated between 90 lb (41 kg) and 138 lb (63 kg). While
bingeing, Y would eat as much as she could in short periods of time, including unprocessed foods
such as wheat flour. She would only stop when her stomach hurt. If prolonged enough (usually
one to two weeks), these phases would lead to some weight gain and abdominal bloating. Y then
would feel despair because of “how fat” she had become. As a result, she spent long periods
hiding in her room, lying in bed, watching TV and “doing nothing.”
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This would be followed by more protracted periods of restriction during which she mainly ate
steamed vegetables and drank only water. Her weight would drop and then she was “ready to go
on with my life.” She would go out with girlfriends, but became so fatigued she often had to return
home and for bedrest.
After forming a working alliance with her current therapist over several months, she resumed
university classes, after having lost two semesters. Despite this apparent improvement, Y was in a
severe restriction phase and knew she was “being ill.” She described that “at the beginning of each
restriction phase my stomach hurts because of the terrible hunger,” but then this yields to a “nice
feeling in my body, which is still pain but reaffirms myself as a real person and actually makes me
sort of feel ‘high.’” Y also described her enjoyment with the idea that other people would notice
her abnormally low weight and think “She really isn't doing well” or “Look at her, she's so skinny
she's obviously sick.” This was true even for strangers she would encounter in the street, but it
was especially comforting to imagine her father and her therapist noticing and worrying about her
cachectic state.
Y had pants of different sizes, and there was one pair that she knew “when it fits, that means I
really am pretty sick.” While wearing these pants, she would think of her father and her therapist,
imagining how frustrated and at the same time concerned they would be that her physical
condition had deteriorated so much. Y used these pants as a marker of the damage she had done
to herself through starvation—they were symbolic of the aggression she had inflicted on herself.
At the same time, however, these pants connected Y to her father and her therapist at these times
of suffering.
By exploring the use of these particular pants as a transitional object, a gradual shift occured in the
therapy. The patient felt understood in a way she never had before, and she had a better
understanding of her desperation around losing weight. Over the next four months, the focus
shifted away from her eating-disordered behaviors (which were coming under better control,
apparently of their own accord). In therapy sessions, the patient and therapist were now dealing
more directly with issues of Y's devastatingly low self-esteem and the family dynamics that helped
foster and maintain this. At some point, the therapist learned that the patient had developed a
new transitional object—now making use of the green card given to her at the front desk after
each session, with the name of the therapist and the date of the next appointment. Y now held
this card close to her at all times, and referred to it when she felt an upsurge of anxiety and urges
to restrict or binge. At this early point in therapy, her weight has stabilized at 136 lbs (62 kg) and
her menses have
- 461 -
returned. Whereas the urge for binges and restrictions remains, Y feels that “I cannot go on
looking for gratification in this way, and need to find something else.” For example, she has been
working full-time in her father's business for the last three months, and her depressive symptoms
have largely remitted.
Case 3. Bulimia Nervosa and BPD
Z, a 19-year-old single female patient, lived with her mother and father. Her maternal aunt and
uncle also lived in the same building. Z's mother owned a retail shop that specialized in the sale of
candies, cakes, and cigarettes.
Z's psychiatric symptoms had started at the age of nine, in the form of extreme weight
preoccupation and periods of dieting, but without amenorrhea. At that time Z had had her
menarche already, and “had started developing a woman's body,” per her account.
Chronologically, Z related the onset of her weight preoccupation to an episode of molestation by
her father's cousin, who fondled her genitalia, with no nudity or penetration. At the age of 16, Z
reported that her uncle started an overt sexual relationship with her, including sexual intercourse.
At that point, she developed frank symptoms of bingeing and vomiting that brought her to seek
help for the first time.
Z reported she had been vomiting “regularly” for the last three and a half years. Each episode of
vomiting was preceded by a binge on cakes that Z stole from her mother's shop. Before bingeing
on this food, she would open a large number of packages, count the cakes in them, and steal one
cake out of the occasional boxes which contained an odd number of cakes, believing that in this
manner her mother would not discover her. She would spend well over one hour doing this, and
maintained an image of her angry mother throughout this period of time. Z kept a provision of
these stolen cakes hidden in her bedroom's closet, so as to have them readily available “in case I
need them.”
Over time it became clear that one of the times when Z “needed them” was after breaking up with
a boy she had begun to date. In therapy, she was able to identify an important connection
between her bingeing and vomiting and her dating behavior. When she started dating a new
partner, she felt good about herself and the eating disordered behavior all but disappeared.
However, when the young man ended the relationship or failed to follow up on it, she began using
the cakes in earnest—bingeing, vomiting, and hoarding them, all with the image of her angry
mother hovering over these activities. She would think about “how mad
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Mother would be at me if she saw me doing this.” She would stop vomiting only after she saw “a
kind of foam coming out, usually mixed with blood.” Then she felt some relief temporarily. This
behavior resulted in a clinically significant esophagitis, but even this did not prevent Z from further
self-induced vomiting.
Over a six-month period, there were four such cycles that could be identified. The therapist helped
her map out the sequence: (1) separation and abandonment by the boyfriend; (2) feeling
inadequate and intensely dysphoric; (3) experiencing overwhelming urges to go to the cakes,
binge on them, and then vomit them up; (4) picturing her mother present during this entire
sequence; (5) seeing the foam and blood and feeling adequately punished and relieved. Over time,
Z was able to see the pattern and started changing it. Once again, evoking the therapist's figure
through an appointment card or dialing the hospital's main number and then hanging up indicated
that the therapist, as a transference figure, had become part of the transitional experience for this
patient.
Discussion
In the three cases outlined herein we have described specific physical objects (a vial of potassium
chloride, a pair of very tight pants, cakes from the mother's shop) that were used in the service of
self-directed aggression and that proved to have particular meanings for each patient. In addition
to the role of the object in the act or fantasy of self-harm, in each case it also served to remind the
patient of a loved person (parent, therapist). Thus the object allowed the internalized presence of
that person to come forward in the mind of the patient. This helped reduce the patient's
intolerable dysphoric tension. Appreciating this use of the physical object as a transitional object
had valuable implications for each patient's psychotherapeutic treatment. By understanding the
psychological function of the object, progress was possible in reducing or eliminating the self-
destructive behavior. Furthermore, the meaning and use of the transitional object and its role in
self-directed aggression were very similar whether the patient suffered from BPD alone or ED with
BPD and whether the self-harm involved an eating behavior or more traditional forms of self-
mutilation or suicidal fantasies. We now elaborate on these points.
Winnicott formulated the concept of the transitional object in 1953. The prototype is the blanket
or teddy bear that the infant “both creates and finds” for himself. It represents neither “me” nor
“not me,” but is something in between. It serves a soothing function because it is a link
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between an internal representation of an emotionally important object and that actual object in
the external world. In particular, this latter involves the infant's mother, who, at first, must actually
pick up and soothe the child when called upon. Only gradually does the mother become a reliable
internalized object that the young child can conjure up to soothe disruptive feeling states without
her actual presence. However, this internalization remains tenuous for long periods of
development, especially during the separation-individuation phase and before the attainment of
libidinal object constancy at approximately age 36 months (Mahler, Piner, and Bergman, 1975).
Under less than favorable conditions, this reliable internalization is never achieved, and the “good
mother” introject simply cannot be evoked in memory under the stress of separation or angry
feelings (Kernberg, 1975). Here, a transitional object remains necessary to allow some aspects of
the internal object to come into focus in the child's mind. Thus, the transitional object becomes
necessary for the soothing effect.
One of the functions of self-directed aggression is self-soothing (Lewin and Schulz, 1990). This is
true whether the behavior involves self-starvation, bingeing and vomiting, or suicidal fantasies
(Favazza, 1996). We believe that the therapist should seek to understand the patient's
characteristic acts and fantasies of self-harm in great detail. Particular attention should be paid to
the elements that contribute to the self-soothing function—how this is generated and what
internal images of objects are called forth in association to the act. Oftentimes what appears to be
a clearly hostile act is one way of attaching to a love object, what Schulz first referred to as
“warmth by friction” (Schulz and Kilgalen, 1969). The therapist and patient should work to
understand the wish for connection and the way in which this connection serves to reduce
intolerable tension states. Just gaining some understanding of this process can help the patient
reduce the intensity of the self-directed aggression. As this is better understood, alternative
methods of self-soothing may be possible. This may involve other, safer objects “both created and
found” by the patient to serve a transitional function. This happened in one of our cases, where
the clinic appointment card proved a good transitional object, replacing the destructive use of the
too-tight pants. In another case, sharpening the focus on the image of the therapist's face and
voice while holding the physical object (the vial of potassium chloride) made the vial less necessary
and the suicidal preoccupations less urgent. Eventually, the patient may progress to the point
where she internalizes a reliable image of a good-enough mother that can survive separations and
anger; this new reliable image often takes the form of the therapist as transference object.
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Patients with comorbid ED and BPD are notoriously difficult to treat effectively—more difficult
than patients with either disorder alone (Coker et al., 1993; Dulit et al., 1994; Rossiter, Agras,
Telch, and Schneider, 1993, Steiger, Stotland, and Houle, 1994; Steiger & Stotland, 1996;
Wonderlich, Fullerton, Swift, and Klein, 1994). Often these patients are highly symptomatic and
respond poorly to psychopharmacological interventions or purely behavioral strategies. They have
great difficulty establishing a working alliance and require much time and patience in this regard.
In a managed care environment, these problems may be exacerbated due to the pressures for
“time-effective therapy” pushed by the third party. As we have described elsewhere (Guinjoan &
Ross, 1999), this puts an additional burden on the therapist's psychotherapeutic skills and
technique. Understanding the role of transitional objects in the acts and fantasies of self-directed
aggression can be very helpful in both establishing a therapeutic alliance with these patients and
in devising strategies to reduce the most destructive overt symptomatology.
Finally, we would like to note that there seem to exist similarities between ED and BPD patients
above and beyond the psychodynamic meanings of their self-directed aggression (Parry-Jones &
Parry-Jones, 1993). Some of the phenomenological aspects of these disorders may have common
developmental and neurobiological bases (Coid, Allolio, and Rees, 1983; Demitrack, Putman,
Brewerton, Brandt, and Gold, 1990). For example, increased levels of endogenous opiods are
associated with self-mutilation episodes and with bingeing and vomiting episodes (Coid et al.,
1983; Davis and Claridge, 1998; Marrazzi, Luby, Kinzie, Munjal, and Spector, 1997). Exposure to
physical and sexual abuse and emotional neglect during childhood is common in patients with ED
and BPD alone or in combination (Everill & Waller, 1995; Gleaves & Eberenz, 1994). Whether these
biological, psychodynamic, and developmental similarities have a common substrate or warrant
considering BPD and ED as manifestations of a more basic single entity is a matter that deserves
further investigation.
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Article Citation [Who Cited This?]
Guinjoan, S.M., Ross, D.R., Perinot, L., Maritato, V., Jordá-Fahrer, M. and Fahrer, R.D. (2001). The
Use of Transitional Objects in Self-Directed Aggression by Patients with Borderline Personality
Disorder, Anorexia Nervosa, or Bulimia Nervosa. J. Am. Acad. Psychoanal. Dyn. Psychiatr., 29:457-
467

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Guinjoan, S.M., Ross, D.R., Perinot, L., Maritato, V., Jordá-Fahrer, M., Fahrer, R.D. (2001).

The Use of Transitional Objects in Self-Directed Aggression by Patients with Borderline

(2001). Journal of American Academy of Psychoanalysis, 29:457-467

Case I. BPD Without ED

Case 2. Anorexia Nervosa with BPD

Case 3. Bulimia Nervosa and BPD

Article Citation [Who Cited This?]

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