Psychosomatics 41:433-435, October 2000
© 2000 The Academy of Psychosomatic Medicine
The Use of a Transitional Object in the Context of Medical Illness
Avram H. Mack, M.D., and
Milton Viederman, M.D.
Received September 8, 1999; revised November 5, 1999; accepted February 4, 2000. From Harvard-Longwood Psychiatry Residency Training Program and the Department of Psychiatry, Cornell University Medical College. Address reprint requests to Dr. Mack, Department of Psychiatry, The Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA 02115.
Key Words: Transitional Object • borderline personality disorder • coping skills
The presence of a stuffed animal at the bedside of an adult patient should be of interest to those in psychiatric consultation. Such objects are often associated with borderline personality disorder, and there are a number of reports in the literature about that relationship.1 One study found that among adult asthma patients, those who had the "positive teddy bear sign" were more likely than matched control subjects (patients without stuffed animals) to meet criteria for an Axis II diagnosis. No difference was found in the rate of Axis I disorders, however.2 But it remains unclear whether a stuffed animal at the patient's bedside always implies a personality disorder or any mental disorder at all. The following case of an elderly woman who used a toy monkey to deal with the loss of her husband and her own worsening medical status illustrates how coping skills used under these circumstances reflect established patterns.
Case Report
A consultation was requested for Mrs. E., a 77-year-old White widowed female surgical inpatient with no previous psychiatric history because she was noted to be communicating with a stuffed animal monkey, which the staff thought abnormal. She had been in her usual state of mental health until 6 months before consultation when her husband of 55 years suddenly died after a myocardial infarction. After this loss, Mrs. E. experienced loneliness, sadness, and at times wished to be dead as well. Her loneliness worsened because her pet dog of many years had been put to sleep by the husband just weeks before his own death.
Three months before consultation the patient was diagnosed with transhiatal esophageal cancer. Esophagectomy, seen as curative, was performed by Dr. B. at this hospital. The postoperative course was uneventful and it was during this first admission that Mrs. E. was given a toy stuffed monkey as a gift by her granddaughter. Mrs. E. had an affinity for the monkey that she named "Jim" after her late husband. She carried the monkey everywhere she went, and she spoke to it as if it were a person. Mrs. E. was aware that others thought this to be a strange practice, but she "didn't care," noting, "they'll all get theirs someday." In a rehabilitation center after surgery Mrs. E. angrily defended herself when a roommate, speaking to friends behind a curtain, referred to Mrs. E as "nuts." In response, Mrs. E. pulled open the curtain and yelled to them, "I am not crazy!"
Mrs. E. continued to suffer additional losses. While at the rehabilitation center she had developed dysphagia as well as an overall motor deconditioning, requiring the current readmission to this hospital. She was angry at the rehabilitation facility for "not doing their job" in helping her heal, but she looked at her surgeon, Dr. B., as a savior. Tragically, Dr. B. was killed in an accident the day before Mrs. E. was to be readmitted to this hospital, and she was "devastated." She disliked her new surgeon, especially after he bluntly stated that she might never again be able to eat normally and that, in the meantime, she required the indefinite placement of a percutaneous enterojejunostomy tube for nutrition. She also was found to have some bilateral vocal cord paralysis that was not amenable to treatment. The patient's course was also complicated by c. difficile infection, which required isolation. As her hospital stay progressed, she felt increasingly lonely and continued talking to "Jim"—"because there's not anyone else to talk to." Mrs. E. had always spoken to pets as if they were people, asserting that since childhood she had been talking to dolls or pets whenever she felt alone or isolated. Although she did not think it abnormal, she was aware that others would. Thus, during the current admission Mrs. E. had been taking "Jim" with her wherever she went, talking to him, and inviting other people to "play along." She would speak to "Jim" in a way people talk to pets—that is, in a high-pitched tone. She would also speak for the toy in roughly the same tone, moving him around as he "spoke." Nonetheless, talking to "Jim" gave Mrs. E. relief by easing her burden of loneliness.
Mrs. E. denied a past psychiatric history. She was born to a married couple in a small northeastern city. She had been very close to her father, and her fondest memories include greeting him at the train station every day. However, she was alienated from both her mother and sister who were abusive to her, making her do work and chores. Feeling lonely and rejected at a young age, Mrs. E. turned to solitary play. She spent many hours alone, interacting with dolls and pets as if they were human. In her school years Mrs. E. had few friends. But she enjoyed the company of her father's parents, who lived nearby. Mrs. E. and her sister became increasingly estranged over their lifetimes. Their father died when they were in late middle age. At that time he was in Mrs. E.'s care following the complications of a stroke, which Mrs. E. blames her sister for causing. She also asserts that her sister maneuvered to get "ten times as much money" as she did on their mother's death.
The mainstay of Mrs. E.'s life was her marriage. She and her husband had been married for over 55 years. They enjoyed a close, intimate relationship with easy resolution of conflict, "always before going to bed," as well as the completion of large projects, in particular the construction of a lake house in Vermont—"I designed it, he built it." They spent most of their time on their own as a couple, with few friends. They enjoyed the company of a dog who was "like one of the family." The dog slept with Mr. and Mrs. E. and went everywhere with them. Mrs. E. often would speak to the dog as if it were a human.
On examination Mrs. E. was frail, yet relaxed, dressed in a hospital gown, sitting in a chair doing crossword puzzles. There was a stuffed animal on the nearby table. She was alert, oriented, and cooperative. Her thought was goal-directed, though mildly tangential. She denied abnormal perceptions and ideas of reference. Examination of higher cortical functions revealed no abnormalities, although she had poor insight about her medical condition, blaming the rehabilitation facility for her deteriorating capacity to swallow.
In summary, this was a 77-year-old woman hospitalized for complications of esophagectomy trying to cope with the pain of multiple losses: of husband, dog, her relationship with her daughter, her trusted surgeon, and the ability to eat normally. All had left her with an increasing sense of loneliness and isolation. The sadness of grief, rather than depression, characterized this woman. The diagnosis was adjustment disorder, characterized predominantly by grief.
Mrs. E.'s object relations used splitting to a significant degree. Trustworthy and good were her husband, Dr. B., her son, her son's son, her dog, and "Jim." Malevolent and uncaring were her mother, her sister, her older daughter, her son's daughter, and her new physician. "Jim" was a transitional object that personifies the good, wished-for, ideal protective mother. Her life had been filled with such objects, starting with her dolls when ignored by mother, continuing with a rich marriage and a dog, and ending with "Jim."
Winnicott3 elaborated the idea of the "transitional object," which remains important for the adult as well as the child. He notes, "This intermediate area of experience, unchallenged in respect of its belonging to inner or external (shared) reality, constitutes the greater part of the infant's experience and throughout life is retained in the intense experiencing that belongs to the arts and to religion and to imaginative living, and to creative scientific work."3 Later workers, including Anna Freud,4 further developed the idea by classifying transitional objects into primary and secondary, according to the age where the object is used. Primary transitional objects are used in the first year; secondary ones come later in life. We would add that the transitional object can be used, even in late adulthood, in response to immediate loss.
The initial transitional object is used as a way of symbolically maintaining and controlling a relationship with mother. How does it function with Mrs. E.? Her use of secondary transitional objects began early in her life as an adaptive coping mechanism. Her primarily positive relationships in life were with men. In their absence, she turned to transitional objects. When her father was away at work she sought refuge from her mother and sister in inanimate objects. For many years she had seen her pet dog as a close friend. And now, hospitalized, away from her son, she has taken up a relationship with "Jim." "Jim" represents the men in her life who have been her saviors and, we might speculate, unconsciously served as the good maternal object in contrast to the "women" who she felt consistently hurt her.
As noted by Stern and Glick,5 the stuffed animal at the bedside is not always a transitional object. In this case "Jim" is a transitional object, and his presence is significant both to the patient and to the medical team who seemed startled to see her talking to him. It is important to remember that, although such an object is no "teddy bear sign" of borderline personality disorder, it is a tip-off to the pain and suffering that is being experienced by the patient who employs it. In general, this fascinating case should remind us that all patients (and their stuffed animals too) deserve an evaluation that is individualized and that does not make unwarranted a priori assumptions. Doing so in this case revealed a touching history for a complex medical case.
REFERENCES
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Cardasis W, Hochman JA, Silk KR: Transitional objects and borderline personality disorder. Am J Psychiatry 1997; 154:250–255[Abstract]
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Schmaling K, DiClementi JD, Hammerly J: The positive teddy bear sign: transitional objects in the medical setting. J Nerv Ment Dis 1994; 182:725[CrossRef]
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Winnicott DW: Transitional objects and transitional phenomena: a study of the first not-me phenomena. International Journal of Psychoanalysis 1953; 34:89–97
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Busch F, Nagera H, McKnight J, et al: Primary transitional objects. Journal of the American Academy of Child Psychiatry 1973; 12:193–214[Medline]
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Stern T, Glick R: Significance of stuffed animals at the bedside and what they can reveal about patients. Psychosomatics 1993; 34:519– 521[Free Full Text]
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