Understanding Co-Occurring Axis I and Axis II Disorders: A Qualitative Single Case Study of Trauma, Personality Pathology, and Social Marginalization in a Female Offender

Female offenders with co-occurring Axis I and Axis II disorders represent an underserved and underresearched population within correctional and mental health systems. Despite high prevalence rates of complex psychopathology among incarcerated women, limited research has examined the intersection of trauma, personality pathology, and social marginalization in this population. This qualitative single case study explored the lived experience and clinical presentation of a female offender (Dorothy) diagnosed with co-occurring Antisocial Personality Disorder, Borderline Personality Disorder, Post-Traumatic Stress Disorder, and Substance Use Disorders. Grounded in attachment theory, trauma theory, and the biopsychosocial model, this study employed an in-depth case study methodology to examine how early developmental trauma, interpersonal dysfunction, and systemic failures contributed to complex psychopathology and criminal behavior. Data were collected through clinical interviews, psychological assessments, correctional records, and collateral sources, and analyzed using thematic analysis with open, axial, and selective coding procedures. Six primary themes emerged: (1) Trauma as a Developmental Disruptor, highlighting the cascading effects of childhood maltreatment; (2) Fragmented Identity and Interpersonal Chaos, revealing unstable self-concept and relationship patterns; (3) Violence as Communication and Control, demonstrating maladaptive expressions of power; (4) Substance Use as Maladaptive Coping, illustrating self-medication patterns; (5) Manipulation and Deception as Survival Strategies, reflecting learned adaptive responses; and (6) Social Marginalization and System Failure, exposing systemic barriers to care. Findings contribute to theoretical understanding of co-occurring disorders, inform trauma-informed clinical interventions for justice-involved women, advance qualitative methodology in forensic psychology, and provide policy recommendations for integrated treatment approaches. This research underscores the critical need for gender-responsive, trauma-informed care within correctional settings and highlights the importance of addressing social determinants of mental health in marginalized populations. Keywords: antisocial personality disorder, borderline personality disorder, post-traumatic stress disorder, substance use disorder, co-occurring disorders, trauma, female offenders, qualitative case study