An Empirical Examination of Soothing Tactics Borderline Personality Disorder

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Randy A. Sansone, Mark A. Fine, and James K. Mulderig Little empirical information is available regarding the process of self-soothing in borderline individuals, as well as in normal subjects. This study examined the frequency of use of soothing “things,” soothing “behaviors,” and soothing “psychological activities” in three groups: borderline personality disorder, major depressive disorder without concurrent personality disorder, and college students. Results indicated that: (1) borderline individuals reported using soothing things at comparable levels to the other two groups; (2) borderline subjects and those with major depressive disorders used more adaptive soothing behaviors than did college students; (3) borderline subjects used more maladaptive soothing behaviors than the other two groups; and (4) borderline individuals used psychologically soothing activities at frequencies comparable to the other two groups. These results are intended to begin the process of developing a soothing profile for individuals with borderline personality disorder. Copyright 0 1991 by W.B. Saunders Company

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HE USE OF concrete, tangible objects for self-soothing remains an area of controversy, particularly from the perspectives of normal development and psychopathology. With reference to normal development in early childhood, these concrete tangibles have been referred to as transitional objects, a term originally introduced by Winnicott.’ Many authorities perceive the early usage of transitional objects to be a normal developmental process for many, but perhaps not all, healthy children.2-4 The evidence from cross-cultural studies suggests that transitional objects are universal and there may be higher rates of utilization in cultures where there is less physical contact with caretakers.‘.” Hong3 has even suggested a developmental sequence involving a shift from the usage of “soft cuddly” tangibles (primary transitional objects) to the later usage of “hard” ones (secondary transitional objects). During adult life, some authorities have felt that the usage of concrete tangibles continues,7,8 but that they appear in differing forms at each stage of life.’ With respect to psychopathology, some studies have found that the early absence of transitional objects was related to later psychopathology.10~‘2 In contrast, others have reported that the prolonged and/or maladaptive use of transitional objects was related to borderline personality in adolescents and adults.13-16 Two studies have employed psychometrically sound measures of the use of general soothing tactics and, in particular, concrete soothers. Using the Transitional Object Scale of the Rorschach and a Transitional Relatedness Interview, Cooper et al.17found that some aspects of transitional relatedness (operationalized as the current use of activities to create a “soothing illusion”) positively correlated with borderline personality, but that there was little evidence to suggest

From the Laureate Pvchiatric Clinic and Hospital, Tulsa, OK. Address reprint requests to Mark A. Fine, Ph.D., Department Dayton, OH 45469-1430. Copyright 0 1991 by W.B. Saunders Company OOIO-440X/91/3205-0007$03.OOiO Comprehensive

of Psychology,

Psychiatry, Vol. 32, No. 5 (September/October),

University of Dayton,

1991: pp 431-439

431

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that this was a unique or diagnostic feature of this population. Similarly, Morris et al.” found that the reported use of transitional objects (based on a Transitional Relatedness Interview) in both childhood and adulthood was high in individuals with borderline personality disorder, but was also common in several of their nonborderline samples. From these data and our own clinical observations, we began to hypothesize a developmental theory of soothing. Incorporating the developmental theories of Bowlby (attachment), Mahler (object constancy and separation/individuation), Kernberg (developmental model of internalized object relations), and Piaget (cognitive development), we postulated the following: (1) Early drastic attachment deficiencies will inhibit the development of the relational skills required for the formation of attachments to concrete tangibles (i.e., transitional objects). (2) There is a normal developmental sequence for the initiation, usage, and relinquishing of transitional concrete tangibles (e.g., blankets, stuffed animals), which may vary according to the amount of physical contact between child and caretaker. (3) In the course of normal development, the method of self-soothing may shift from a preponderance of concrete soothers to abstract (i.e., psychological) soothers. In addition, the concrete soothers of adult life may take on a more elusive, less obvious, and more sophisticated quality than those of children. (4) Due to the early developmental dilemmas in borderline individuals (e.g., failure to attain object constancy due to the impairment of evocative memory and the failed resolution of splitting), they may rely on a preponderence of concrete rather than psychological soothers. The following study was designed to specifically test the last postulate. Soothing profiles were examined for four subject groups: (1) borderline personality disorder; (2) borderline personality disorder with major depression; (3) major depressive disorder; and (4) college students. An assessment instrument was designed to measure the subjects’ usage of soothing things, adaptive and maladaptive soothing behaviors, and soothing psychological activities (i.e., a soothing profile). It was hypothesized that when compared with controls and non-character-disordered psychiatric subjects, the soothing profiles of the borderline subjects would demonstrate higher usage of soothing things and maladaptive soothing behaviors, and lower usage of adaptive soothing behaviors and soothing psychological activities. METHOD

Subjects Subjects were 97 individuals recruited from four different clinical settings-two private hospitals, an Air Force inpatient unit, and an Air Force outpatient service-and from introductory psychology classes at a private midwestern university. Four groups were identified: (1) 14 individuals with borderline personality disorder without accompanying current/acute axis I diagnoses; (2) 11 individuals with borderline personality disorder and major depressive disorder; (3) 29 individuals with major depressive disorder without accompanying personality disorder; and (4) 43 college students completing a research requirement in introductory psychology. DSM-III-R diagnoses in the three clinical groups were made by attending psychiatrists in each setting without knowledge of the patients’ scores on the instruments used in this study.

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In the three clinical groups, again on the basis of psychiatrists’ judgments, subjects with dramatic narcissistic, histrionic, or antisocial personality traits were excluded because of evidence that these personality styles have symptoms that overlap with those of borderline personality disorder.” The advantage of having these exclusion criteria is that the resulting sample of individuals with borderline personality disorder is likely to be more homogeneous and “pure.” However, because these other personality characteristics often coexist with borderline personality, the sample may not be typical of the general population of borderline individuals. Because those with borderline personality without major depression (group 1) did not significantly differ on either measure of borderline functioning from those having both borderline personality and major depressive disorder (group 2), these two groups were combined. Thus, the three diagnostic groups used in the analyses presented below were: major depressive disorder (MDD), borderline personality disorder (BPD), and college students (CS). Means and standard deviations for each group on demographic and psychiatric history variables are presented in Table 1. One-way (diagnostic group) analyses of variance and Student-Neuman-Keuls post-hoc tests (P < .05) on the continuous demographic and psychiatric history variables showed that: (a) the MDD group was older than the BPD group, which, in turn, was older than the CS group; (b) those in the MDD and BPD groups had more marriages and divorces than those in the CS group; (c) those in the BPD group reported having more psychiatric hospitalizations and outpatient treatment experiences than did either the MDD or CS groups. Chi-square analyses on categorical demographic and psychiatric history variables indicated that: (a) there were no differences in gender composition across the three groups; (b) the CS group was more educated than the BPD and MDD groups; (c) the BPD and MDD groups were more likely to be presently married than the CS group; (d) both psychiatric groups were more likely to have taken antianxiety, antidepressant, and/or antipsychotic medications than the CS group; and (e) the BPD group was more likely to report having family members who had seen mental health professionals, been hospitalized for psychiatric disorders, had drug/alcohol problems, and who had committed suicide. Because these differences are generally consistent with expected differences among BPD, MDD, and CS groups, the demographic and family history variables were not used as covariates in the analyses that are described below.

Table 1. Descriptive Statistics on Demographic and Psychiatric History Variables by Diagnostic Group Diagnostic Group BPD

Age W No. of marriages No. of divorces No. of psychiatric hospitalizations No. of outpatient treatment experiences % Female % High school graduate % Married % Employed % Who use medications Antianxiety Antidepressant Antipsychotics Family history (%) Seen professionally Been hospitalized Had drug problem Had alcohol problem Attempted suicide *Values are means -e SD.

30.3 1.0 .4 6.9 2.2

+ + + 2 2 84 72 58 44

8.0* .9 .8 20.0 2.9

MDD 43.3 ? 1.3 -c .4? 1.2 f .9 * 73 69 59 61

12.7 .5 .6 1.4 1.0

cs 19.0 2 1.6 Ok0 050 .o + .2 .o + .2 61 98 0 2

64 68 48

59 86 28

0 0 0

68 48 54 72 32

53 41 14 29 14

28 18 12 40 5

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Znshumeniation Subjects completed a research booklet that contained the following instruments. A Background Information form was developed by the investigators to gather basic demographic information (e.g., age, marital status, occupational status, education) and psychiatric history (number of treatment experiences, use of medications, and family history). The Borderline Syndrome Znde.8’ (BSI) is a 5%item, self-report questionnaire designed to assess borderline symptomatology in the areas of poor impulse control, absence of a consistent self-identity, depression, anhedonia, impaired object relations, depersonalization, and a number of “neurotic symptoms.” The BSI successfully discriminates borderlines from normal controls and patient groups easily distinguishable from borderline personality disorder (e.g., schizophrenia, depression),“‘l but not from other patient groups with overlapping symptomatology (e.g., schizotypal personality).2’ In the present study, Cronbach’s alpha was .95. The Borderline Scale of the Personality Disorder Questionnaire-Revised22 (PDQ-R) is a self-report measure that contains 12 items that assess the DSM-III-RU diagnostic criteria for borderline personality disorder. Previous studies using the borderline scale from the original PDQ found it to be an expedient screen for the presence of borderline psychopathology and to have adequate psychometric properties.24.25Cronbach’s alpha was .81. Because there are no already-existing measures of soothing strategies, the Soothing Questionnnaire was designed by the investigators for use in this study to assess how individuals soothe or calm themselves in times of emotional distress. It contains four scales, based on the nature of the soother. On all four scales, response options ranged from 1 (not at all) to 5 (always). Soothing things (14 items) assesses what and how often specific objects are used as soothers. The specific objects are pets, stuffed animals, lucky charms, photographs, greeting cards that you have received, old letters from friends, diary, new cologne/perfume, dolls, new hairstyle, specific article of clothing, rosary, makeup, and blanket. A total score was computed as the sum of the ratings on the individual items and could range from 14 to 70. Cronbach’s alpha was .83, indicating excellent internal consistency. Adaptive soothing behaviors (16 items) measures how often specific actions judged to be adaptive are used as soothers. The specific behaviors are ironing clothes, cooking, cleaning, exercising, bathing, rearranging rooms or furniture, watching television, talking aloud to self for reassurance, crying, going to church, listening to records, driving a car, talking to significant other for reassurance, reading a book, making lists, and having sex. A total score was computed by summing ratings on the individual items and could range from 16 to 80. Cronbach’s alpha was .76. Muladaptive soothing behaviors (16 items) assesses how often specific actions judged to be maladaptive are used as soothers. Specific behaviors include smoking cigarettes, taking recreational drugs, drinking alcohol, screaming or shouting, sleeping, shopping, gambling, hitting walls, breaking things, cutting yourself with a sharp object, overdosing on drugs, burning yourself, hitting yourself, getting into fights, overeating or binging, and stealing. A total score was computed by summing ratings on the individual items and could range from 16 to 80. Cronbach’s alpha was .72. PsychoZogicaf activities (10 items) assesses the frequency with which abstract activities that require thought and/or imagery are used to self-soothe. Specific items are recalling pleasant memories, recalling unpleasant memories, thinking of a loved one, internally reassuring oneself, being creative, meditating, praying, reading the bible, making lists, and reassuring self about the future. A total score was computed by summing ratings on the individual items and could range from 10 to 50. Cronbach’s alpha was .74.

Procedure For the patient groups, physicians at the various clinical settings were informed of the purpose and nature of the study to elicit their referral of patients who met the study criteria. When a physician made a referral, nurses on the unit/service, psychiatry residents, or psychology interns explained the purpose of the study to the patient, supplied him/her with a written patient information brochure describing the study, answered any questions about the study, and, if the patient chose to participate, asked the patient to read and sign consent forms (one for the hospital and one for the project files). Patients were then given the research booklet, asked to independently complete it in their rooms, and told to return it to the clinic coordinator or unit clerk when completed. The college students were tested in two groups of 20 to 25 in a university classroom. They were told

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that the study was designed to explore how people differ in the way they cope with stress. After completing the research booklets, they were given a debriefing sheet that described the study in more detail.

RESULTS

Two approaches were taken to test the hypotheses. First, a categorical approach was used to test whether the BPD group had higher scores on the soothing things and maladaptive soothing behavior scales of the Soothing Questionnaire and lower scores on the adaptive soothing behavior and psychological activities scales than did the MDD and CS groups. Second, correlational analyses were computed to test whether the degree of borderline psychopathology (as measured by BSI and PDQ-R scores), independent of diagnostic group, was related in the expected directions to scores on the scales of the Soothing Questionnaire. Comparisons Among Diagnostic Groups

To adequately test the hypotheses, it was important to insure that the diagnostic groups differed in the extent of borderline psychopathology. Means and standard deviations on the BSI and the borderline scale of the PDQ-R are presented in Table 2. Separate one-way (diagnostic group) analyses of variance were computed with BSI and PDQ-R scores serving as dependent variables. As expected, there were significant effects for diagnostic group on both instruments (BSI: [F(2,94) = 40.11, P < .OOOl]; PDQ-R: [F(2,93) = 18.32, P < .OOOl]). StudentNeuman-Keuls post-hoc tests showed, in both cases, that the BPD group had significantly higher scores (P < .OS) than the MDD group, which had higher scores than those in the CS group. Thus, as expected, the BPD group reported greater borderline psychopathology than did the other two groups. Means and standard deviations on the four scales of the Soothing Questionnaire for each diagnostic group are presented in Table 2, along with the percentage in each group who received a mean score on the instrument that indicates that the soothers on the scale were used more often than “rarely.” A Table 2. Means and Standard Deviations on Dependent Diagnostic Group

and Independent

Variables by

Diagnostic Group

BSI PDQ-R Soothing things % More than “rarely” Adaptive soothing behaviors % More than “rarely” Maladaptive soothing behaviors % More than “rarely” Psychological activities % More than “rarely”

BPD

MDD

cs

27.5 5 8.8* 7.2 k 2.6 28.3 t 8.2 45.5 42.6 k 7.5 95.0 30.4 rf: 6.0 28.6 26.5 f 5.7 90.5

18.6 + 11.7 4.6 2 3.2 25.8 2 10.1 40.0 41.0 2 9.4 85.7 25.5 2 5.4 15.4 27.0 2 7.5 87.0

7.5 k 7.0 3.2 ? 2.4 26.2 k 8.6 31.7 36.8 k 9.5 73.7 23.0 -r- 5.4 9.8 24.4 2 6.9 70.7

NOTE. “% More than rarely” indicates the percentage of subjects in each diagnostic group whose mean score on the scale was higher than “2” (rarely), indicating that their mean use of the items on the particular scale was more frequent than “rarely.” “Values are means it SD.

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series of two-way (diagnostic group and gender) analyses of variance were computed on the four scales of the Soothing Questionnaire. There were significant effects for diagnostic group on the adaptive soothing behaviors scale [F(2,76) = 3.13, P < .05] and the maladaptive soothing behaviors scale [F(2,85) = 12.30, P < .OOOl]. Student-Neuman-Keuls post-hoc tests indicated that the BPD and MDD groups had higher scores (P < .05) on the adaptive soothing behavior scale than the CS group. Further, the BPD group had higher scores on the maladaptive soothing behavior scale than either the MDD or CS groups. This indicates that the borderline group reported using more maladaptive behaviors to soothe themselves than did the other groups. There were no gender effects on any of the analyses. Correlations Between Borderline Measures and Soothing Scales

For all diagnostic groups combined, Pearson correlations were computed between the two measures of borderline psychopathology (BSI and PDQ-R) and the four scales from the Soothing Questionnaire. It was predicted that scores on the borderline measures would be positively correlated with scores on soothing things and maladaptive soothing behaviors and negatively correlated with scores on adaptive soothing behaviors and psychological activities. Significant correlations were found between the BSI and maladaptive soothing behaviors (r = Sl, P < .OOl) and between the PDQ-R borderline scale and maladaptive soothing behaviors (r = .63, P < .OOl). Thus, there was a positive relation between the extent of borderline psychopathology and the use of maladaptive behaviors as soothers. No other correlations reached statistical significance. DISCUSSION

The most striking contribution of this study was the initial compilation of a soothing profile for patients with borderline personality disorder. When compared with individuals with major depressive disorder and college students, borderline patients reported: (1) comparable usage of soothing things, not higher usage; (2) comparable usage of adaptive soothing behaviors to major depressives, with both groups higher than controls; (3) higher usage of maladaptive soothing behaviors than either group; and (4) surprisingly, comparable usage of psychologically soothing activities. In interpreting these findings, the possibly select nature of the borderline sample used in this study should be highlighted. By excluding those with concurrent axis I and axis II disorders (with the exception of major depressive disorder in some of the borderline subjects), the sample is quite homogeneous, but may have limited generalizability to the general population of borderline individuals. However, it should also be noted that it is possible that the clinicians who referred patients to the study minimized their report of other axis I/II features on the premise that the borderline psychostructure was the predominant element driving the symptomatology (e.g., affective symptoms). Compared with the CS group, the BPD and MDD groups had higher scores on the adaptive soothing behavior scale. Recalling that these scores are a summation of the individual items, several conclusions might be drawn. It may be that individuals with these two types of psychopathology need to employ a broader repertoire of adaptive soothing behaviors than normal controls. In other words, the psychodynamic dilemma for psychiatric patients may be that a few select

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limited soothing behaviors are not sufficient to provide and insure soothing (i.e., a variety of behaviors need to be undertaken to achieve emotional restitution). If so, one might wonder if this dilemma-the inability to efficiently self-soothe-is a common developmental denominator in other types of psychopathology. This hypothesis could be easily explored by administering the adaptive soothing behavior scale to a diagnostically heterogenous group of psychiatric subjects. An alternative possible explanation of this finding is a developmental one. It could be that younger subjects have not yet consolidated an identifiable repertoire of soothing behaviors. This hypothesis, again, could be examined by administering the adaptive soothing behavior scale to nonpsychiatric subjects representing a broad age range and exploring whether there is a direct relation between age and number of identified soothing behaviors. The finding that borderline subjects employed more maladaptive soothing behaviors to self-sooth than the two other subject groups was anticipated. The use of self-destructive behaviors to sooth is hypothesized to reflect a repetitioncompulsion due to an early malignant and intrusive environment. To date, a variety of studies have documented the high prevalence of early physical and/or sexual abuse in the developmental histories of borderline individuals.‘“3’ In addition, investigations have documented that repeated self-destructive behaviors are specific to this population.3”33 Several potentially significant and unexpected findings occurred in this study. The first is that borderline subjects did not report different levels of usage of soothing things (i.e., tangible objects) when compared with the other two subject groups. However, it may be that borderline subjects use tangible objects for soothing with greater psychological intensity than the other groups. This hypothesis remains to be tested, as the soothing scales in this study were designed to measure self-reported frequency rather than psychological intensity. A second unexpected finding was that borderline subjects, compared with the MDD and CS subjects, reported comparable usage of adaptive soothing behaviors, as well as soothing psychological activities. We had predicted that the borderline subjects would score lower than the other subjects in both of these areas, particularly with psychological soothers. The reported use of soothing psychological activities by the borderline subjects suggests that therapists may have a psychological substrate to work with and enhance in the treatment process. At the same time, this finding may be chnically misleading, as the capacity for psychological soothing may be immobilized during times of intense stress (i.e., “cognitive freezing”).34 Thus, during intense stress, borderline individuals may be unable to access their skills to psychologically soothe themselves. Because of differing methodologies and instrumentation, our results are difficult to compare with previous studies in this area. These findings may appear to be inconsistent with those studies that found an early absence of transitional objects in subjects’ who subsequently developed psychopathology.“-‘” However, while this study assessed how borderline adults soothed themselves, several of the other investigations assessed the adult consequences of the reported absence of transitional object usage during childhood. This study assessed the present use of soothers, whereas these other studies explored either clinicians’ or patients’ perceptions of childhood experiences. The present results are consistent with those studies and clinicians who

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reported prolonged and/or maladaptive use of transitional objects in borderline subjects,13-‘6 as the borderline subjects in this study engaged in the use of maladaptive soothing behaviors more frequently than those in the other groups. However, the finding that borderline individuals used soothing things at levels comparable to those in the other subject groups is in conflict with these previous findings. One factor that may explain this inconsistency is a potential difference in the functional levels of the borderline subjects in the different studies. As noted below, we strongly suspect that ours were high functioning and may have “mimicked” normal. Several methodological issues need to be considered in the interpretation of these data. First, the clinical sites where the study was conducted were acute care settings. The military hospital, in particular, was a major triage point for young, newly diagnosed military personnel. Thus, borderline subjects from these clinical sites may have been higher functioning than those seen in community mental health and state hospital settings. A second issue is the validity of the self-report method. Psychiatric subjects may have attempted to appear more “normal” on self-report instruments, although we doubt this. On the contrary, we and others have felt that borderline subjects, in particular, may report higher levels of psychopathology and dysfunction on self-report instruments than in personal interviews.24 A third issue is the psychometric properties of the Soothing Questionnaire. Although a number of soothing tactics were incorporated (56 items), its comprehensiveness as a soothing inventory is not known. Further, whereas the scales of the instrument were internally consistent, future research will be needed to further substantiate the reliability and validity of the Soothing Questionnaire. Finally, the use of college students as normal controls is always a potential dilemma. The implication of their differing demographics, particularly their younger ages, is unclear. The extent to which college students are representative of the general, nonpsychiatric population is unknown. In conclusion, the data did not clearly substantiate our clinical theory regarding the predicted differences in soothing profiles for the three groups studied. For the borderline subjects, the theory might be further tested by: (1) exploring the psychological intensity in their use of soothing things, and (2) assessing their ability to access the acknowledged psychological soothers during times of high stress. These two variables may be the underlying subtleties necessary to confirm the postulated theory. Future research in this pioneering area may profit from attempts to assess these two dimensions and their relation to borderline personality disorder. REFERENCES 1. Winnicott DW: Transitional objects and transitional phenomena: A study of the first not-me possession. Int J Psychoanal 34:89-97, 1953 2. Ekecrantz L, Rudhe L: Transitional phenomena: Frequency, forms and functions of specially loved objects. Acta Psychiatr Stand 48:261-273,1972 3. Hong KM: The transitional phenomena. Psychoanal Study Child 33:47-79,1978 4. Passman RH: Attachments to inanimate objects: Are children who have security blankets insecure? J Consult Clin Psycho1 55825830,1987 5. Gaddini R, Gaddini E: Transitional objects and the process of individuation. J Am Acad Child Psychiatr 9:347-365,197O

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15:49-61,1976 7. Kahne MJ: On the persistence of transitional phenomena into adult life. Int J Psychoanal 48:247-258, 1976 8. Coppolillo HP: Maturational aspects of the transitional phenomenon. Int J Psychoanal 48:237-246,1967 9. Rosenthal PA: Changes in transitional objects: Girls in midadolescence. Adolesc Psychiatry 9:214-226, 1981 10. Provence S, Ritvo S: Effects of deprivation on institutionalized infants. Psychoanal Study Child 16:189-205,196l 11. Horton PC, Louy JW, Coppolillo HP: Personality disorder and transitional relatedness. Arch Gen Psychiatry 30:618-622, 1974 12. Lobe1 L: A study of transitional objects in the early histories of borderline adolescents. Adolesc Psychiatry 9:199-213,198l 13. Model1 AH: Object Love and Reality. New York, NY, International Universities Press, 1968 14. Fintz RT: Vicissitudes of the transitional object in a borderline child. Int J Psychoanal 52:107-114. 1971 15. Arkema PH: The borderline personality and transitional relatedness. Am J Psychiatry 138:172-177,198l 16. Giovacchini PL: The borderline adolescent as a transitional object: A common variation. Adolesc Psychiatry 12:233-250,1985 17. Cooper SH, Perry JC, Hoke L, et al: Transitional relatedness and borderline personality disorder. Psychoanal Psycho1 2:115-128,1985 18. Morris H, Gunderson JG, Zanarini MC: Transitional object use and borderline psychopathology. Am J Psychiatry 143:1534-1538, 1986 19. Gunderson JG, Zanarini MC: Current overview of the borderline diagnosis. J Clin Psychiatry 48:5-11,1987 20. Conte HR, Plutchik R, Karasu T, et al: A self-report borderline scale: Discriminative validity and preliminary norms. J Nerv Ment Dis 168:428-435,198O 21. Edell WS: The Borderline Syndrome Index: Clinical validity and utility. J Nerv Ment Dis 172:254-263,1984 22. Hyler SE, Rieder, RO: Personality Diagnostic Questionnaire-Revised. New York, NY, New York State Psychiatric Institute, 1987 23. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (ed 3, revised). Washington, DC, APA, 1987 24. Hurt SW, Hyler SE, Frances A, et al: Assessing borderline personality disorder with self-report, clinical interview, or semistructured interview. Am J Psychiatry 141:1228-1231,1984 25. Pfohl B, Coryell W, Zimmerman M, et al: Prognostic validity of self-report and interview measures of personality disorder in depressed inpatients. J Clin Psychiatry 48:468-472, 1987 26. Herman JL, Perry JC, Van der Kolk BA: Childhood trauma in borderline personality disorder. Am J Psychiatry 146:490-495, 1989 27. Ludolph PS, Westen D, Misle B, et al: The borderline diagnosis in adolescents: Symptoms and developmental history. Am J Psychiatry 147:470-476,199O 28. Ogata SN, Silk KR, Goodrich S, et al: Childhood sexual and physical abuse in adult patients with borderline personality disorder. Am J Psychiatry 147:1008-1013,199O 29. Shearer SL, Peters CP, Quaytman MS, et al: Frequency and correlates of childhood sexual and physical abuse histories in adult female borderline patients. Am J Psychiatry 147:214-216,199O 30. Links PS, Steiner M, Offord DR, et al: Characteristics of borderline personality disorder: A Canadian study. Can J Psychiatry 33:336-340, 1988 31. Zanarini MC, Gunderson JG, Frankenburg FR, et al: Discriminating borderline personality disorder from other axis II disorders. Am J Psychiatry 147:161-167,199O 32. Shearer SL, Peters CP, Quaytman MS, et al: Intent and lethality of suicide attempts among female borderline inpatients. Am J Psychiatry 145:1424-1427, 1988 33. Zanarini MC, Gunderson JG, Marino MF, et al: Childhood experiences of borderline patients. Compr Psychiatry 30:18-25,1989 34. Dennis AB, Sansone RA: Treating the bulimic patient with borderline personality disorder, in Johnson C (ed): Advances in Eating Disorders, ~012. Greenwich, CT, JAI, 1989, pp 237-265

An empirical examination of soothing tactics in borderline personality disorder.

Little empirical information is available regarding the process of self-soothing in borderline individuals, as well as in normal subjects. This study ...
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