Axis I:  303.90 Alcohol Dependence

            R/O 307.42 Primary Insomnia

Axis II: 301.6 Dependent Personality Disorder and Borderline Traits

Axis III: None reported

Axis IV: Relationship Problems

Axis V: GAF = 45

Mr. A.* is a Persian adult male who is currently employed as the king of a large, Middle-Eastern empire*. A. initially presents with a tendency toward severe alcohol dependence. He reported that he recently hosted a 180-day party in which alcohol was consumed continuously. Soon afterward he hosted another 7-day party, perhaps to mitigate the symptoms of withdrawal. His level of intoxication causes him to make impulsive decisions, without thinking through the consequences. At the above-mentioned party, he ended up divorcing his wife and later regretting the decision when he woke up the next day.

After carefully reviewing his actions, it becomes clear that the alcohol dependence is merely the initial symptom that masks many underlying personality issues. A. appears to self-medicate using the alcohol to mask deep feelings of insecurity and impaired self-esteem. A. does not speak about his life before becoming king but collateral contacts report that he came from humble beginnings, but was successfully able to marry into Persian royalty. Reportedly, this was a source of marital tension between A. and his first wife, V.* (Esther Rabba 3:14). It is possible that he never accepted his quick rise to power and his inability to make important decisions on his own reflects a primary need for and identification with others. Although he appears to be successful on the surface, he struggles to make decisions on his own. He is highly suggestive, and in an effort to please others, often quickly agrees to anything asked of him, without thinking through the consequences. Despite his fame and power, he continues to act like a helpless young boy, searching eternally for his mother’s unrequited love.

He appears to approach relationships, particularly with women, in a borderline or fragmented way. At times, he reveres the women he claims to love, but he can turn on them quickly as illustrated by the example above. His current wife, E*, fears for her life when she goes to see him, not knowing if he will kill her or embrace her. Little is known about his early object relations, but one could conjecture that he had an inadequate resolution of his Oedipal Phase, as evidenced by his clear fears of castration, his large gold scepter that never leaves his hand, and his deep unconscious conflict over his amassed wealth. He has a difficult time holding on to his possessions, repeatedly giving away his ring, money, or even half his kingdom. In fact, he recently approached the therapist for a fee reduction after giving away 20,000 silver pieces to an apparently psychopathic friend named H*. Perhaps he experiences an unconscious belief that he is in fact undeserving of his success.

* Names and identifying information have been removed to protect the confidentiality of the patient