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.*
RODOLFO D. FAHRER, M.D., PH.D.*

It is well known that there is a significant epidemiologic overlap be-

tween 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 biochemi-
cal variables (Verkes, Pijl, Meinders, and Van Kempem, 1996), develop-
mental events (Everill and Waller, 1995), and family dynamics (Waller,
1994) in these syndromes. An association between borderline personal-
ity 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.
Journal of The American Academy of Psychoanalysis, 29(3), 457–467, 2001
© 2001 The American Academy of Psychoanalysis
458 GUINJOAN ET AL.

Self-directed aggression is a prominent clinical feature of both BPD

and ED. Self-mutilation is a specific diagnostic feature of BPD (Ameri-
can Psychiatric Association, 1994). Patients with ED frequently cause
serious self-harm through self-starvation, repeated self-induced vomit-
ing, 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 esopha-
geal tears from their vomiting, which makes this self-destructive behav-
ior 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 com-
plicating 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 promi-
nent 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 facili-
tate, contain, and structure the act or fantasy of self-harm. We demon-
strate how these objects served a transitional function as first described
by Winnicott (1953). Specifically, the object served to connect the pa-
tient 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 hos-

pital 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
 TRANSITIONAL OBJECTS 459

the therapist, especially around scheduled time away (weekends and es-
pecially 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 re-
lieve her separation dysphoria.
In the second year of therapy, W began to steal drugs from the medi-
cation supply at work and stockpile them with the expressed intent of
using them to commit suicide when she “felt bad enough.” She gath-
ered 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 thera-
pist when “planning” her suicide. Sometimes this would take up hours
of an otherwise miserable and lonely day. She especially found it help-
ful 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 medica-
tion 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 potas-
sium vial in hand, the image was comforting and clear. The suicide fan-
tasy quickly dropped out of the picture.
Over the next year, W used a vial of potassium chloride as a transi-
tional 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 demand-
ing she turn over the vials to him in the past. Now she had an image of
460 GUINJOAN ET AL.

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 thera-
peutic 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 psycho-
therapy 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 mater-
nal 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 combi-
nations). During her inpatient stay, she used a metal ring she was wear-
ing 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 oscil-
lated 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 peri-
ods hiding in her room, lying in bed, watching TV and “doing nothing.”
 TRANSITIONAL OBJECTS 461

This would be followed by more protracted periods of restriction dur-

ing 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 sev-
eral months, she resumed university classes, after having lost two se-
mesters. Despite this apparent improvement, Y was in a severe restric-
tion 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 physi-
cal 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 com-
ing 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
462 GUINJOAN ET AL.

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 fuIl-time in
her father’s business for the last three months, and her depressive symp-
toms 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 moles-
tation 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 num-
ber of cakes, believing that in this manner her mother would not dis-
cover her. She would spend well over one hour doing this, and main-
tained 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 part-
ner, 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
 TRANSITIONAL OBJECTS 463

Mother would be at me if she saw me doing this.” She would stop vom-
iting 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) separa-
tion and abandonment by the boyfriend; (2) feeling inadequate and in-
tensely 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 num-
ber 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 physi-

cal 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 psychologi-
cal function of the object, progress was possible in reducing or elimi-
nating 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 elabo-
rate 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
464 GUINJOAN ET AL.

between an internal representation of an emotionally important object

and that actual object in the external world. In particular, this latter in-
volves 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 in-
ternalization 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” in-
troject simply cannot be evoked in memory under the stress of separa-
tion or angry feelings (Kernberg, 1975). Here, a transitional object re-
mains 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 ob-
ject, 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 thera-
pist’s face and voice while holding the physical object (the vial of po-
tassium chloride) made the vial less necessary and the suicidal pre-
occupations 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.
 TRANSITIONAL OBJECTS 465

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, I996;
Wonderlich, Fullerton, Swift, and Klein, 1994). Often these patients are
highly symptomatic and respond poorly to psychopharmacological in-
terventions 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 devis-
ing strategies to reduce the most destructive overt symptomatology.
Finally, we would like to note that there seem to exist similarities be-
tween ED and BPD patients above and beyond the psychodynamic mean-
ings of their self-directed aggression (Parry-Jones & Parry-Jones, 1993).
Some of the phenomenological aspects of these disorders may have com-
mon developmental and neurobiological bases (Coid, Allolio, and Rees,
1983; Demitrack, Putman, Brewerton, Brandt, and Gold, 1990). For ex-
ample, 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 emo-
tional 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 de-
serves further investigation.

References

American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental

Disorders (4th ed.), American Psychiatric Press, Washington DC.
Becker, A. E., Grinspoon, S. K., Klibanski, A., and Herzog, D. B. (1999), Eating disor-
ders, New England Journal of Medicine, 340, 1092–1098.
Coid, J., Allolio, B., and Rees, L. H. (1983), Raised plasma metenkephalin in patients who
habitually mutilate themselves, Lancet, 2(8349), 545–546.
Coker, S., Vize, C., Wade, T., and Cooper, P. J. (1993), Patients with bulimia nervosa who
466 GUINJOAN ET AL.

fail to engage in cognitive behavior therapy, International Journal of Eating Disor-

ders, 13, 35–40.
Davis, C., and Claridge, G. (1998), The eating disorders as addiction: A psychobiological
perspective, Addictive Behaviors, 23, 463–475.
Davis, C., Claridge, G., and Cerullo, D. (1997), Personality factors and weight preoccupa-
tion: A continuum approach to the association between eating disorders and personal-
ity disorders, Journal of Psychiatric Research, 31, 467–480.
Demitrack, M. A., Putnam, F. W., Brewerton, T. D., Brandt, H. A., and GoId, P. W. (1990),
Relation of clinical variables to dissociative phenomena in eating disorders, American
Journal of Psychiatry, 147, 1184–1188.
Dulit, R. A., Fyer, M. R., Leon, A. C., Brodsky, B. S., and Frances, A. J. (1994), CIinical
correlates of self-mutilation in borderline personality disorder, American Journal of
Psychiatry, 151, 1305–1311.
Everill, J. T., and WaIler, G. (1995), Reported sexual abuse and eating psychopathology:
A review of the evidence for a causal link, International Journal of Eating Disorders,
18, 1–11.
Favazza, A. R. (1996), Bodies under Siege, Johns Hopkins University Press, Baltimore.
Favazza, A. R., DeRosear, L., and Conterio, K. (1989), Self-mutilation and eating disor-
ders, Suicide and Life-Threatening Behavior, 19, 352–361.
Gershuny, B. S., and Thayer, J. F. (1999), Relations among psychological trauma, disso-
ciative phenomena, and trauma-related distress: A review and integration, Clinical Psy-
chology Review, 19, 631–657.
Gleaves, D. H., and Eberenz, K. P. (1994), Sexual abuse histories among treatment-resistant
bulimia nervosa patients, International Journal of Eating Disorders, 15, 227–231.
Grilo, C. M., Levy, K. N., Becker, D. F., Edell, W. S., and McGlashan, T. H. (1996),
Comorbidity of DSM-III-R Axis I and II disorders among female inpatients with eat-
ing disorders, Psychiatric Services, 47, 426–429.
Guinjoan, S. M., and Ross, D. R. (1999), The use of metaphors by the “ambulatory inpa-
tients” of the managed care era, American Journal of Psychotherapy, 53, 188–200.
Herzog, D. B., Keller, M. B., Lavori, P. W., Kenny, G. M., and Sacks, N. R. (1992), The
prevalence of personality disorders in 210 women with eating disorders, Journal of
Clinical Psychiatry, 53, 147–152.
Kernberg, O. (1975), Borderline Conditions and Pathological Narcissism, Aronson, New
York.
Lewin, R., and Schulz, C. G. (1990), Losing and Fusing, Aronson, New York.
Mahler, M., Pine, F., and Bergman, A. (1975), The Pschological Birth of the Human Infant,
Basic Books, New York.
Marrazzi, M. A., Luby, E. D., Kinzie, J., Munjal, I. D., and Spector, S. (1997), Endogenous
codeine and morphine in anorexia and bulimia nervosa, Life Sciences, 60, 1741–1747.
Matsunaga, H., Kaye, W.H., McConaha, C., Plotnicov, K., Pollice, C., and Rao, R. (2000),
Personality disorders among subjects recovered from eating disorders, International
Journal of Eating Disorders, 27, 353–357.
Parry-Jones, B., and Parry-Jones, W. L. (1993), Self-mutilation in four historical cases of
bulimia, British Journal of Psychiatry, 163, 394–402.
Rossiter, E. M., Agras, W. S., Telch, C. F., and Schneider, J. A. (1993), Cluster B person-
ality disorder characteristics predict outcome in the treatment of bulimia nervosa, In-
ternational Journal of Eating Disorders, 13, 349–357.
Sansone, R. A., Fine, M. A., Seuferer, S., and Bovenzi, J. (1989), The prevalence of bor-
derline personality symptomatology among women with eating disorders, Journal of
Clinical Psychology, 45, 603–610.
 TRANSITIONAL OBJECTS 467

Schulz, C. G., and Kilgalen, R. K. (1969). Case studies in schizophrenia. Basic Books,
New York.
Skodol, A. E., Oldham, J. M., Hyler, S. E., Kellman, H. D., Doidge, N., and Davies, M.
(1993), Comorbidity of DSM-III-R eating disorders and personality disorders, Inter-
national Journal of Eating Disorders, 14, 403–416.
Steiger, H., and Stotland, S. (1996), Prospective study of outcome in bulimics as a func-
tion of Axis-Il comorbidity: Long-term responses on eating and psychiatric symptoms,
International Journal of Eating Disorders, 20, 149–161.
Steiger, H., Stotland, S., and Houle, L. (1994), Prognostic implications of stable versus
transient “borderline features” in bulimic patients, Journal of Clinical Psychiatry, 55,
206–214.
Szabo, C. P. (1993), Blood-letting in bulimia nervosa, British Journal of Psychiatry, 162,
708.
Treasure, J., and Serpell, L. (1999), Osteoporosis in anorexia nervosa. Hospital Medicine,
60, 477–480.
Verkes, R. J., Pijl, H., Meinders, A. E., and Van Kempen, G. M. (1996), Borderline per-
sonality, impulsiveness, and platelet monoamine measures in bulimia nervosa and re-
current suicidal behavior, Biological Psychiatry, 40, 173–180.
Waller, G. (1994), Borderline personality disorder and perceived family dysfunction in the
eating disorders, Journal of Nervous and Mental Disease, 182, 541–546.
Winnicott, D. W. (1953), Transitional objects and transitional phenomena, A study of the
first not-me possession, International Journal of Psycho-Analysis, 34, 89–97.
Wonderlich, S. A., Fullerton, D., Swift, W. J., and Klein, M. H. (1994), Five-year outcome
from eating disorders: Relevance of personality disorders, International Journal of
Eating Disorders, 15, 233–243.
Yates, W. R., Sieleni, B., Reich, J., and Brass, C. (1989), Comorbidity of bulimia nervosa
and personality disorder, Journal of Clinical Psychiatry, 50, 57–59.

Departmento de Salud Mental

Hospital de Clinicas “José de San Martin”
Ave. Córdoba 2351 5to Piso
(1120) Buenos Aires
Argentina
E-mail: [email protected]