PSYCH 650 Week 5 Substance Use and Personality Disorders Example

Seven Crisis Visits in a Year: Alcohol Use Disorder, Borderline Personality Disorder and Treating Both at Once

[Student Name]

University of Phoenix

PSYCH/650: Psychopathology

Week 5 Assignment

[Instructor Name]

[Date]

The crisis unit, its staff and the client are composites written for a model paper; diagnostic criteria and research findings come from the sources listed.

Substance use disorders and personality disorders are common, frequently occur together and complicate one another's treatment. Ms. K.'s seven crisis visits in one year show how tightly the two can bind together.

The Case

Ms. K., thirty-two, manages a busy restaurant in Scottsdale, Arizona. Over the past year, she came to our crisis stabilization unit seven times. Each visit followed the same sequence: a conflict with her partner, often after she suspected he would leave, followed by heavy drinking, usually a bottle of wine and several shots, and then a crisis call, twice after cutting her forearms. Between crises she functions well at work. Most evenings she opens a bottle meaning to have one glass and finishes it. Promises to cut back have not lasted, she has skipped her niece's birthday after a bad night, she keeps drinking though she knows it darkens her mood, it now takes more to feel anything and her hands shake on many mornings. Since her teens she has had intense, short relationships that swing between idealization and anger, a persistent fear of abandonment, an unstable sense of who she is, impulsive spending and chronic feelings of emptiness. Her parents divorced when she was eight, and she describes her mother's moods as unpredictable.

Substance Use Disorder and Its Severity

The DSM-5-TR (American Psychiatric Association, 2022) lists eleven signs of a substance use disorder, covering loss of control over use, damage to work and relationships, use in dangerous situations and the body's adaptation, shown as tolerance and withdrawal. How many signs show up within a twelve-month window sets the grade, so a person showing a couple of signs is graded mild, a middle count moderate and a long list severe; the cut points are two, four and six.

Ms. K. clears the six-sign mark: overshooting her limits, failing to cut back, letting obligations slide, drinking through mood problems alcohol worsens, needing more for the same effect and morning withdrawal. This places her alcohol use disorder in the severe range.

How Common Is Alcohol Use Disorder?

Grant et al. (2015) drew on face-to-face interviews with more than thirty-six thousand American adults in a federal survey of alcohol and related conditions. Twelve-month prevalence of DSM-5 alcohol use disorder was about fourteen percent and lifetime prevalence about twenty-nine percent. People with the disorder often had other drug problems, mood disorders or antisocial or borderline traits, and they carried more disability. Fewer than one in five had ever been treated.

Personality Disorder Criteria

A personality disorder is a long-running way of thinking, feeling and relating that sits far outside what a person's culture expects, shows up across most settings, resists change, starts by the teens or early twenties and causes suffering or trouble functioning. For borderline personality disorder, the manual asks for five of nine signs of instability in relationships, self-image and feelings, along with impulsivity. Ms. K.'s history shows desperate attempts to stop partners leaving, relationships that flip from adoration to fury, an unsteady sense of who she is, reckless spending and drinking, repeated cutting, fast-changing moods and a lasting inner emptiness.

Ms. K.'s history includes at least six of these features, beginning in adolescence and present when sober as well as when drinking, which supports the diagnosis rather than attributing the pattern to alcohol alone.

Her crises begin with a fear that someone will leave and end with a bottle; treatment has to reach both ends.

How Often Personality Disorders Occur

Trull et al. (2010) reanalyzed personality disorder diagnoses from a large national survey using stricter requirements that symptoms cause distress or impairment. Using these revised criteria, about nine percent of adults met criteria for at least one personality disorder, and borderline personality disorder affected about 2.7 percent. Personality disorders were strongly associated with substance use disorders and other mental disorders, and borderline personality disorder in particular showed high rates of co-occurring alcohol and drug use disorders.

Ruling Out Other Explanations

Before settling on these diagnoses, the team considered alternatives. Bipolar disorder can produce impulsivity and unstable mood, but Ms. K.'s mood shifts last hours and follow interpersonal triggers, rather than lasting days with changes in sleep and energy. Posttraumatic stress disorder can resemble borderline personality disorder, and she reported a difficult childhood; screening found no specific traumatic event or PTSD symptoms, though the team noted the question for her outpatient therapist. Alcohol-induced depressive disorder was considered for her low mood, but her emptiness and identity disturbance predate heavy drinking. Clarifying these alternatives matters because each points to different treatment.

The Dimensional View of Personality Disorders

The DSM-5-TR also includes an alternative model for personality disorders, in which clinicians rate impairments in personality functioning, such as identity and intimacy, and pathological traits across domains such as negative affectivity and disinhibition. In that model, Ms. K. would be described by severe impairment in identity and intimacy and elevated negative affectivity and disinhibition, a description that some clinicians find more useful for treatment planning than a category.

How the Two Interact

For Ms. K., the conditions feed one another. Fear of abandonment and emotional intensity trigger conflict; alcohol temporarily numbs distress but lowers inhibition, increasing impulsive acts such as cutting; the aftermath, shame, hangover and a partner's anger, deepens emotional instability. Treating either condition alone leaves the other driving the cycle.

Treatment Evidence

Linehan et al. (2006) assigned women with borderline personality disorder and recent suicide attempts or self-injury, by chance, either to dialectical behavior therapy or to therapists in the community nominated as experts. Across twelve months of therapy and twelve more of follow-up, the DBT group made roughly half the suicide attempts, went to emergency rooms and psychiatric wards less often for suicidal crises and quit treatment less often. DBT combines individual therapy, skills training in mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness, phone coaching and a consultation team for therapists.

Versions of DBT have been adapted for people with substance use disorders, combining its skills with attention to substance use goals. For alcohol use disorder, effective approaches also include motivational interviewing, cognitive behavioral therapy, mutual help groups and medications such as naltrexone.

Stigma and Staff Attitudes

People with borderline personality disorder often meet frustration from staff, especially when they return to crisis services repeatedly. Some of our staff had begun to describe Ms. K. as "manipulative" and her visits as "attention seeking." Such labels misread behavior that, in her experience, follows overwhelming emotion, and they can make care worse. A brief team discussion of DBT's view, that behavior makes sense in light of a person's emotional vulnerability and learning history, helped staff respond with consistency rather than irritation.

The Plan

The team developed a safety plan with Ms. K., referred her to a DBT program that accepts clients with co-occurring substance use, discussed medication for alcohol use disorder with the unit psychiatrist, who prescribed naltrexone, and arranged a follow-up appointment within a week. She agreed to attend.

Conclusion

Ms. K. meets criteria for severe alcohol use disorder and borderline personality disorder, two common and frequently co-occurring conditions that fuel each other. Research on prevalence, co-occurrence and dialectical behavior therapy supports integrated treatment that addresses emotional instability, drinking and safety together.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Grant, B. F., Goldstein, R. B., Saha, T. D., Chou, S. P., Jung, J., Zhang, H., Pickering, R. P., Ruan, W. J., Smith, S. M., Huang, B., & Hasin, D. S. (2015). Epidemiology of DSM-5 alcohol use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry, 72(8), 757-766. https://doi.org/10.1001/jamapsychiatry.2015.0584

Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., Korslund, K. E., Tutek, D. A., Reynolds, S. K., & Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757-766. https://doi.org/10.1001/archpsyc.63.7.757

Trull, T. J., Jahng, S., Tomko, R. L., Wood, P. K., & Sher, K. J. (2010). Revised NESARC personality disorder diagnoses: Gender, prevalence, and comorbidity with substance dependence disorders. Journal of Personality Disorders, 24(4), 412-426. https://doi.org/10.1521/pedi.2010.24.4.412