Journal of Personality Disorders, 29(2), 215–230, 2015 © 2015 The Guilford Press

RELATIONSHIP BETWEEN TRANSITIONAL OBJECTS AND PERSONALITY DISORDERS IN FEMALE PSYCHIATRIC INPATIENTS: A PROSPECTIVE STUDY Carlos Schönfeldt-Lecuona, MD, Ferdinand Keller, PhD, Markus Kiefer, PhD, Maximillian Gahr, MD, Paul L. Plener, MD, Manfred Spitzer, MD, PhD, Ingo M. Gunst, MSc Psych, Torsten Fischer, MSc Psych, Bernhard J. Connemann, MD, and Markus M. Schmid, MD Patients often bring transitional objects (TO) to inpatient units. The authors quantified the frequency of TO possession in an inpatient psychiatric setting and assessed whether TO use is specific to a personality disorder (PD) diagnosis, focusing on borderline PD (BPD). TO possession was assessed using the Transitional Objects Questionnaire, and PD diagnosis was established using standard DSM-IV clinical interviews. Of the 104 female patients assessed, 57.7% showed TO use; 84% of BPD patients, 71% of BPD-trait patients, 65% of patients with PD traits (other than BPD), and 56% of PD patients (other than BPD) displayed TO use, whereas 30.6% of patients without PD showed TO use. Patients with TOs were significantly younger and had significantly longer hospital stays. The specificity and sensitivity for TO use in the BPD group were 0.506 and 0.84, respectively. The authors conclude that TO use is closely related to PD diagnosis, but is not specific to BPD.

In childhood, relationships with inanimate objects that hold a special emotional value, such as stuffed toys, animals, and blankets, are quite common and seem to support personality development (Winnicott, 1953). In some instances, the attachment to such a transitional object (TO) continues into adulthood, possibly serving to reduce affective distress and playing a role in emotion regulation. Empirical research on TO use in psychiatric patients is limited to a few studies. It has been consistently re-

This article was accepted under the editorship of Robert F. Krueger and John Livesley. From Department of Psychiatry and Psychotherapy III, University of Ulm, Germany (C. S.-L., M. K., M., G., M. S., I. M. G., T. F., B. J. C., M. M. S.); and Department of Child and Adolescent Psychiatry and Psychotherapy, University of Ulm, Germany (F. K, P. L. P.). Carlos Schönfeldt-Lecuona and Ferdinand Keller contributed equally to this article. Address correspondence to Carlos Schönfeldt-Lecuona, MD, Professor in Psychiatry, University of Ulm, Department of Psychiatry & Psychotherapy III, Leimgrubenweg 12-14, 89075 Ulm, Germany; E-mail: [email protected]

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ported that TO use is most pronounced in patients with borderline personality disorder (BPD), who typically show increased emotional distress and suffer from emotion regulation deficits. Morris, Gunderson, and Zanarini (1986) were the first to describe a positive correlation between using TOs and a BPD diagnosis. A further study demonstrated a link between TO use and a dysfunctional personality style among 176 medical inpatients with asthma (Schmaling, DiClementi, & Hammerly, 1994). The most recent survey conducted by Cardasis, Hochman, and Silk (1997), which included 146 inpatients, showed a sensitivity of 63% for a BPD diagnosis in the case of TO use and a positive predictive power of 45%. In light of the investigation by Cardasis et al., we aimed to reevaluate the relationship between TO use and personality in an inpatient population using standardized diagnostic instruments for personality disorders (PD). In particular, we aimed to assess whether TO use also extends beyond BPD to other PDs and accentuated personality traits (PTs). We considered accentuated PTs and PDs to lie along the personality continuum, with accentuated PTs (as detected by the Structured Clinical Interview for DSM-IV Axis II Personality Disorders [SCID-II]) as a milder variation of PDs but not reaching the clinical diagnosis of a PD based on a consensus statement using DSM-IV criteria (see Methods for the diagnostic procedure). A further aim was to identify the correlations between TO use and personality traits, as assessed using the Dimensional Assessment of Personality Pathology Questionnaire (DAPP-BQ). Finally, one of the most distinctive symptoms of BPD, nonsuicidal self-injury (NSSI, Criterion 5 of the DSM-IV classification of BPD), was quantified and compared with TO possession.

METHODS PARTICIPANTS Because females predominate (approximately 80%) among inpatients who suffer from BPD (Skodol et al., 2002), only female participants were recruited from the general inpatient population of our hospital. The sample included patients with all psychiatric disorders except those that would preclude the provision of informed consent to participate in the study. The exclusion criteria were being younger than 18 years or older than 50 years, current treatment in the secure psychiatric ward, mental retardation, acute psychotic state (or an organic cause impeding cooperation, independent of diagnosis), and substantial difficulties in reading and writing in the German language that resulted in the inability to complete the required inventories or tests. The required inventories (see below) were completed within the first week of inpatient treatment if the patient agreed to enter the study. The study was approved by the Internal Review Board of the University of Ulm (346/09-UBB/se); written informed consent was obtained from each of the participants before they entered the study.

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INSTRUMENTS The following inventories were used for participant diagnosis or categorization. (1) The SCID-II was used to assess personality disorders (Spitzer, Williams, & Gibbon, 1990). First, patients completed the screening inventory. If the cutoff was reached, the second part of the inventory (a personal interview) was conducted by one of two experienced, master’s-level psychologists (T.F., I.M.G.). These psychologists were blinded to the screening inventory results, and they had no therapeutic relationship to the participants. (2) The Transitional Objects (TO)-Questionnaire (provided by Dr. Kenneth R. Silk, Ann Arbor, MI, USA) (Cardasis et al., 1997) was used to assess TO use. This inventory consists of 24 items. It categorizes TOs (either brought to the hospital or left at home) with regard to emotional importance (“not important,” “less important,” “quite important,” or “essential”), how the object was obtained, and its physical appearance. Additional information included the function of the TO (e.g., whether the patient needed the object to sleep or in times of distress) and how the patient felt if the object was lost. Furthermore, TO use in childhood was assessed. Consistent with the 1997 study by Cardasis et al., TO was defined as an emotionally important object, categorized in the TO-Questionnaire as “quite important” or “essential.” The Dimensional Assessment of Personality Pathology Question(3)  naire (DAPP-BQ; German version from the University of Bielefeld; Angleitner, Ostendorf, & Riemann, 2001) was utilized to assess personality traits because this inventory serves to identify a dimensional profile of personality. The DAPP-BQ allows for the assessment of personality traits along the full continuum from mild to extreme trait manifestations (Pukrop, 2002). (4) The Self-Harm Behavior Questionnaire (SHBQ) was used to assess the NSSI issue (Gutierrez, Osman, Barrios, & Kopper, 2001).

PROCEDURES All female inpatients sequentially admitted to the psychiatric wards within a 9-month period were asked to participate in this study. The study was performed between November 1, 2009, and July 27, 2010. Upon admission, all patients underwent psychopathological and clinical examinations to establish their psychiatric diagnoses and comorbidities. Within the first week of admission, all female patients who agreed to participate in the study and provided their informed consent were screened for personality disorders using the SCID-II screening inventory. Furthermore, the TOQuestionnaire, the DAPP-BQ, and the SHBQ were administered. After the evaluation with the SCID-II screening inventory, if the cutoff for dysfunc-

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tional personality was reached, an experienced, master’s-level psychologist (who was not involved in therapy) conducted a standard semistructured SCID-II interview. This psychologist had no information about the presence or absence of TO use or the supposed and working diagnosis. At discharge, the diagnosis was again assessed according to the DSM-IV-TR criteria by an independent experienced psychiatrist who was naive to the study purposes and who had no information about the SCID-II results. The diagnosis of PD was made if the SCID-II screening and interview were positive for a specific PD type and the diagnosis was clinically confirmed at discharge, thus securing a high level of diagnostic consistency. Patients with a positive SCID-II interview for a specific PD who, at discharge, did not meet diagnostic criteria for the supposed PD were assigned to the subgroup “personality traits.” Data on patients with the admission diagnosis of accentuated personality traits were also reviewed, and the diagnosis was confirmed at discharge. Depending on the identified traits (SCID-II and interview), patients were then classified into the corresponding group (BPD traits, traits other than BPD). In conclusion, the following five subgroups were created: group 1 = BPD; group 2 = BPD traits; group 3 = other PD; group 4 = other PD traits (other than BPD); and group 5 = no PD, which represented the patients without any PD or PD traits. Data regarding NSSI were acquired through the SHBQ, a well-established diagnostic instrument. According to Brunner, Parzer, and Haffner (2007), repetitive NSSI was considered to be present in patients who reported a minimum of four NSSI incidents. Finally, the 18 dimensions encompassing the quantitative questionnaire (DAPP-BQ) were applied. For statistical analysis, confidence intervals for the percentages, the Mann-Whitney U-test for differences in duration of hospital stay and in DAPP subscales, and a t test for age difference were applied. Differences in age and length of stay between all five diagnostic subgroups were analyzed with the Kruskal-Wallis test.

RESULTS SAMPLE Overall, 153 female inpatients sequentially admitted to the psychiatric ward within a 9-month period were asked to participate in this study. Of these inpatients, 104 (68%) consented to participate in the study. Of the 49 patients who were not included in the final study sample, 36 did not consent to participate in the study. The other 13 patients had to be excluded because of exclusion criteria (six patients had substantial difficulties performing the required inventories because of difficulties understanding written German; in two cases, a significant mental retardation that was unknown at study entry was diagnosed later) and practical reasons (in two cases, the patients were discharged within the first study week, making the participation impossible due to incomplete diagnostic

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procedures; two patients who had agreed to participate in the study dropped out by choice without further explanation). One further patient had to be referred to the secure ward due to suicidality. The age range of the participants was 18–50 years, with a mean age of 35.1 years (SD = 9.8); the mean of length of hospital stay was 36.3 days (SD = 39.4). The group of participants included in the final sample did not significantly differ from the group of patients that did not agree to participate with regard to age (M = 36.9, SD = 9.3; t = 1.08, df = 138, p = .283) and duration of stay (M = 26.4, SD = 23.0; z = −1.74, p = .082). The diagnosis of BPD (group 1) was established in 25 cases (24.0%) (17 with BPD only, eight BPD plus additional PD). Other PDs (group 3) were diagnosed in nine patients (8.7%). Regarding personality traits, BPD traits (group 2) were observed in 17 subjects (16.3%), and other PD traits (group 4) were observed in 17 patients (16.3%). Thirty-six participants (34.6%) did not meet the criteria for any PD (group 5).

TO USE, AGE, AND DURATION OF HOSPITAL STAY Sixty of the participants (57.7%) showed TO use. Altogether 66 TOs were recorded; six patients appeared to have two TOs, each with “essential” or “quite” emotional importance. With regard to all TOs, 56% were stuffed animals, 24% were jewelry, 8% were photographs of loved persons or animals, and 12% were other objects (four pillows, two guitars, one T-shirt, and one small angel figure). Examples of different TOs are shown in Supplementary Figure 1. Within the BPD subgroup, two-thirds of the patients used stuffed animals as a TO. Supplementary Figure 2 shows the distribution of TO use with regard to the diagnostic subgroups. Furthermore, we examined the factor “age” in relation to “presence of TO” or “absence of TO,” independent of psychiatric diagnosis. In this respect, a minor but significant difference between the TO group (M = 33.3, SD = 9.3) and the non-TO group (M = 37.5, SD = 10.0) was found (t = 2.19, df = 102, p = .031). Thus, patients who possessed an emotional object were significantly younger than patients without a TO. With respect to the time patients spent in the inpatient department in relation to the “presence of TO” or “absence of TO,” a significant difference in the duration of the hospital stay was found, with a mean stay of 42.4 (SD = 47.1) days in the TO group and 27.7 (SD = 23.8) days in the non-TO group (z = −1.98, p = .048). An analysis of the five diagnostic subgroups revealed differences in age and length of stay. With regard to age, the BPD group was the youngest (M = 30.4, SD = 7.95), compared to the BPD traits group (M = 33.1, SD = 9.98), the other PD group (M = 32.1, SD = 7.83), the other PD traits group (M = 41.2 SD = 7.73), and the no-PD group (M = 36.5 SD = 10.51). The differences among the groups were significant (χ2 = 15.37, df = 4, p = .004). Post hoc comparisons showed that omitting the BPD group resulted in a nonsignificant difference (χ2 = 7.76, df = 3, p = .051). Thus, the overall difference in age was caused mainly by the young age of the BPD group. With

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Supplementary Figure 1. Examples of transitional objects (TO) used by the study participants.

regard to the length of stay, the BPD group stayed longest (M = 60.8 SD = 68.3) in comparison to the BPD traits group (M = 36.1 SD = 22.3), the other PD group (M = 39.0 SD = 21.6), the other PD traits group (M = 26.4 SD = 15.7), and the no-PD group (M = 23.4 SD = 17.1). The between-group differences were significant (χ2 = 13.79, df = 4, p = .008). Post hoc comparisons showed that when omitting the BPD group, there was no significant difference (χ2 = 6.14, df = 3, p = .105). Thus, the overall difference in the length of stay was caused mainly by the longer duration of hospital stay by the BPD group.

TO USE AND DIAGNOSIS In the five subgroups, we found differences regarding the prevalence of TO use, regardless of whether the TO was left at home or was brought to the hospital. The highest TO use of 84.0% (95% confidence interval [CI],

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Supplementary Figure 2. Schedule showing the different diagnoses with reference to transitional objects (TO) brought to the hospital and their respective frequencies (PD = personality disorder; BPD = borderline personality disorder).

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Figure 1. Percentages of transitional objects (TO) used in relation to PD diagnosis (PD = personality disorder; BPD = borderline personality disorder).

69.6%–98.4%) was found in the BPD group, closely followed by the group of patients with BPD traits (70.6%, 95% CI: 44.0%–89.7%). Furthermore, 55.6% (95% CI: 21.2%–86.3%) of the patients with other PD diagnoses used TOs, and 64.7% (95% CI: 38.3%–85.8%) of those in the group of other PD traits used TOs. Only 30.6% (95% CI: 16.4%–48.1%) of the patients without any PD diagnosis described having TOs (see Figure 1). A comparison of the 95% CIs of the prevalence rates of the five subgroups revealed that only the BPD and the no-PD groups were significantly different. The specificity of TO use was 0.506 in the BPD group and 0.565 in the BPD traits group. For patients diagnosed with any personality disorder, specificity was 0.514, and for the groups having any personality disorder and any personality disorder traits, it was 0.695. The positive predictive value (PPV) was 0.35 for the BPD group, and the negative predictive value (NPV) was 0.90. When the criterion “TOs brought to hospital” was adopted, lower prevalence rates with a higher specificity for BPD or other PD diagnosis or traits were found (Figure 2). Specificity was 0.620 for the BPD group, 0.677 for BPD patients and patients with BPD traits, 0.629 for all personality disorders, and 0.806 for the any PD group and the any PD traits group. When TO use in childhood was assessed, the prevalence varied between 41% and 56%, with no relevant difference found among the five subgroups. Figure 3 shows the relative frequency of TO use during childhood versus adulthood.

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Figure 2. Percentages of transitional objects (TO) brought to the hospital in relation to PD diagnosis (PD = personality disorder; BPD = borderline personality disorder).

NONSUICIDAL SELF-INJURY BEHAVIOR Overall1 we found that 57.7% of our sample presented repetitive NSSI. With regard to the diagnosis, NSSI was present in 88% of the BPD patients (95% CI: 75.3%–100%). In the other subgroups, NSSI was found to a lesser extent: 41.2% in the BPD traits group (95% CI: 18.4%–67.1%), 44.4% in the other PD group (95% CI: 13.7%–78.8%), and 12.5% in the other PD traits group (95% CI: 1.6%–38.4%). Only 13.9% of the patients without any PD (95% CI: 4.7%–29.5%) showed NSSI (cf. Figure 4). A comparison of the 95% CIs revealed that the BPD group had significantly higher NSSI scores than the BPD traits group, the other PD traits group, and the no-PD group.

TO USE AND PERSONALITY DIMENSIONS With regard to the DAPP-BQ subscales, U-tests revealed significant differences at the p < .01 level for the subscales “insecure attachment” and 1. One patient was excluded from the analysis of NSSI because of an incomplete SHBQ form.

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Figure 3. Comparison of transitional objects (TO) used in childhood (front) and adulthood (back) (PD = personality disorder; BPD = borderline personality disorder).

“suicidality,” which includes self-harming behavior. Significant differences at the p < .05 level were found for the subscales “cognitive distortion”, “anxiousness,” and “suspiciousness” (cf. Figure 5).

DISCUSSION This study investigated the relationship of personality to frequency and specificity of TO use in female psychiatric inpatients. Special attention was given to BPD patients, in whom significantly high levels of TO use have been reported in the past (Cardasis et al., 1997; Morris et al., 1986). To our knowledge, the current study is the first to investigate TO use in relation to a patient’s personality using exhaustive analysis of all PD variants and not solely focusing on BPD. Furthermore, the concept of a dimensional model of personality disorders was adapted to detect an association of personality traits with TO use. The reported results generally confirm previous studies regarding an association between TO use and BPD. TO use was found in our study in 84% of BPD patients. Compared to the study by Cardasis et al. (1997), who found TO use in 63% of BPD patients, our data revealed a higher incidence. This result can be partially traced back to the inclusion of exclusively female patients in our cohort. Furthermore, in most psychiatric hospitals, a diagnosis is made in the first days of stay. For the purpose of our study, the diagnosis of a specific PD was made if both the SCID-II screening and the interview were positive for a PD and if the diagnosis was confirmed at discharge by an independent clinician, thus creating a high-

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Figure 4. Percentages of nonsuicidal self-injuries (NSSI) (front) vs. transitional objects (TO) used (back) in relation to PD diagnosis (PD = personality disorder; BPD = borderline personality disorder).

er level of diagnostic confidence. Patients with a positive SCID-II interview for PD who, at discharge, did not meet diagnostic criteria for the supposed PD were assigned to the subgroup “personality traits.” This two-step diagnostic procedure was established to reach a high level of diagnostic consistency. Our study extended the diagnostic classifications by specifying a subgroup of patients with personality traits. If the BPD and the BPD trait group were taken together, a lower percentage of TO use (78.6%) was found, which is closer to the rate reported by Cardasis et al. Moving beyond the assessment used in previous studies, we differentiated all personality disorders according to DSM-IV categories. We found an increased TO use in the other PD groups and in the group showing accentuated personality traits. TO use was particularly accentuated in patients with BPD traits (71%) compared to patients without PD (31%). Moreover, compared with other studies, TO use was found to be nonspecific to BPD. It appears that there are decreasing rates of TO use along a continuum descending from BPD to borderline traits, to other PD, and to no PD. In addition, there was a tendency toward increased TO use in patients with BPD in combination with other personality disorders or traits (see Supplementary Figure 2). This finding supports the notion of greater malfunction in patients with BPD plus another comorbid PD, which may predispose patients to even greater TO use. Our finding that patients with TO were significantly younger could point to ongoing personality development using TOs as stable objects. Patients with TOs exhibited a significantly longer duration of hospital stay; therefore, it could be hypothesized that patients who use TOs are more prone to experience regression during their

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Figure 5. Dimensional Assessment of Personality Pathology (DAPP) box-whisker-plot (minimum, maximum, median, and quartiles) in relation to transitional objects (TO) used. LIE = validity scale; SUIC = self-harm; INS ATT = insecure attachment; NARCIS = narcissism; SOC AV = social avoidance; SUSP = suspiciousness; CONDUCT = conduct problems; ANX = anxiousness; REJECT = rejection; INTIM = intimacy problems; PASS AGG = passive-aggressive behavior; CALLOUS = callousness; REST EXP = restricted expression; COMP = compulsivity; STIM SEEK = stimulus seeking; AFF STAB = affective stability; IDENT = identity problems; COG DIS = cognitive distortion; SUBMIS = submissiveness. **p < .01. *p < .05.

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inpatient stay. Differences among psychiatric diagnoses were observable not only for TO use at the hospital but also for TO use in general. Furthermore, patients did not know how long they would remain in the hospital at the time the assessment was conducted (during the first week of admittance). However, psychiatric diagnosis, age, and length of stay, are most likely confounded by the fact that the BPD group is the youngest one and is also the group with the longest hospital stay. Patients in the BPD group showed significantly higher NSSI than the BPD traits group (88% vs. 41.2%), although in both groups the diagnostic criteria for BPD (according to SCID-II screening and interview) were met at the beginning of the hospital stay. The most plausible explanation for this discrepancy seems as follows: The diagnostic procedure at admittance included patients with a BPD symptom profile irrespective of other existing psychiatric disorders (e.g., major depression, suicidal crisis). Thus, it is likely that some patients fulfilling the BPD criteria at admission may not have actually suffered from BPD (i.e., putative BPD symptoms may have represented symptoms also present in a comorbid disorder and were therefore not specific to BPD). In this case, patients who initially fulfilled BPD criteria did not fulfill the required diagnostic criteria at the end of the hospital stay. According to Winnicott (1953), transitional objects in childhood are recognized as a normal step in personal development. The current results support this hypothesis, as TO use in childhood was similar in all subgroups (no differences were found among the five subgroups). In object relations theory, BPD patients are thought to lack a sense of object constancy (Kernberg & Michels, 2009). Transitional object use in adulthood may indicate dysfunctional object constancy and is greater in BPD patients, as described in previous studies (Cardasis et al., 1997; Morris et al., 1986; Stern & Glick, 1993). It is possible that a deficit in object constancy or in cognitive abilities (e.g., reduced mentalizing ability) is the reason for TO use in adulthood. This corresponds with Kernberg’s (1967, 1987) model that conceptualizes personality disorders dimensionally in relation to object constancy and ego development. In his theory, personality structure consists of three layers: neurotic, borderline, and psychotic. Kernberg would classify a person with borderline personality disorder as having persistently developmentally early internal object relations. The term object relation refers to the self-structure humans internalize in early childhood, which serves as a blueprint for establishing and maintaining future relationships. Contrary to DSM-IV, in Kernberg’s model, the term borderline disorder is a much broader term that includes any severe personality disorder, such as those in DSM-IV Cluster B (borderline, narcissistic, antisocial), and schizoid personality disorders. The present observation of TO use in patients with BPD, but also with other PDs, is consistent with this model. Apart from theoretical models based on psychoanalytical conceptions, findings from recent neurobiological research in social pain can also be

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used for explaining the relation between TO use and PD. The use of a transitional object might have an auxiliary function, enabling the individual to cope better with aversive emotions, feelings of emptiness, and social rejection. Fear of rejection and emotional instability are among the key symptoms of BPD. Recent neuroimaging research showed that social pain (social rejection) and physical pain share a common neural substrate, particularly in the anterior cingulate cortex (ACC) (Eisenberger, Lieberman, & Williams, 2003). As pain intensity correlates with ACC activity (Rainville, Duncan, Price, Carrier, & Bushnell, 1997) and patients with BPD often show increased ACC activation during emotional tasks (Schmahl et al., 2006), it might be speculated that TO use serves as a strategy to reduce emotional distress and possibly “social pain.” In line with this reasoning, an analysis of the DAPP questionnaire revealed a correlation of TO use with specific personality traits. The subscales anxiousness, suspiciousness, cognitive distortion, suicidality, and insecure attachment significantly differed between patients who did and did not use TOs. Particularly for BPD patients, emotional states can be characterized by suicidal behavior, anxiety, suspicious thinking, and dissociative symptoms (cognitive distortion). The observation of an association between TO use and instable emotional personality traits also supports the hypothesis that TOs may function as auxiliary tools for emotion regulation. Our study has some limitations that should be noted. Based on the low prevalence of inpatient male BPD patients (Bohus et al., 2000; Bohus & Schmahl, 2007; Paris, 2004, 2005), we included only female patients. Further investigations are necessary to examine the equivalent of TO use in male patients with PDs. In addition, TO use in childhood was only assessed retrospectively. To examine whether TO use continued into adolescence or began for the first time at a certain age, a prospective study or questioning of close relatives would increase reliability. It might also be interesting to observe the differences in TO use in child and adolescent psychiatric settings. Finally, the circumstances of the study dictated that only inpatient subjects were evaluated. An extension to an outpatient setting is desirable.

CONCLUSION A distinctive difference in TO use in adulthood was demonstrated for patients with BPD, other PD, and borderline traits or other personality disorder traits compared to patients without PD. TO use was most pronounced in BPD patients, as previously reported, but it was also present in patients with other PD. Therefore, TO use is not a specific marker for BPD. However, the NPV was quite high (0.90), indicating that an absence of TO use predicts with high confidence that the negative result is true (i.e., the person does not suffer from BPD). The PPV was relatively small (0.35), indicating that many of the positive results are false positives (i.e., no BPD). Note that PPV and NPV depend on the prevalence of the disorder, which

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may differ in different clinics. Sensitivity, which is, in contrast, not dependent on prevalence rates, was also rather high (0.84) for BPD (i.e., 84% of the BPD patients can be identified by TO use). Therefore, our results suggest that the assessment of TO use may provide a helpful hint in personality disorder diagnosis.

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Relationship between transitional objects and personality disorders in female psychiatric inpatients: a prospective study.

Patients often bring transitional objects (TO) to inpatient units. The authors quantified the frequency of TO possession in an inpatient psychiatric s...
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