Schizoaffective Disorder, depression and bipolar disorder ruled out. No symptoms of major depression or manic episodes present. Suicidal ideation appears to be driven by psychosis and is incongruent with stated beliefs.


Running Head: CASE OF DARYL



Case of Daryl

Jane Doe

<The case of Daryl is located on the last page of this document. Do not include the case in your assignment>

Differential Diagnosis for Daryl

A differential diagnosis for Daryl will include Schizophrenia, Alcohol Use Disorder and Cannabis Use Disorder. Genetic and biological indications will be considered, along with cultural influences. Research shows that “genetic factors account for about 56% of the risk for alcohol dependence” (Sue, 2016, p.349). Daryl reportedly has one biological relative (his grandfather) who died of an alcohol related disorder. The exacerbation of his psychotic symptoms due to the use of substances will also be considered.

Another factor to consider in diagnosis is the role that genetics and heredity play in the development of both schizophrenia and bipolar disorders (Sue, 2016, APA, 2013). Since Daryl’s grandmother has been reportedly diagnosed with schizophrenia and manic-depression, this will be considered in diagnostic formulation. Research shows that the general incidence of schizophrenia is slightly higher in males and that the development of schizophrenia for males is in the early to mid-20’s (APA, 2013). This may be significant as Daryl is a 24-year old male.

Being mindful of Daryl’s culture is also part of the differential diagnosis formulation. Studies show that African-Americans have a higher rate of receiving a diagnosis of schizophrenia compared to other cultural groups. African Americans were over 3 times more likely to receive a diagnosis of schizophrenia (Sue, 2016). Sociocultural and ethnic factors must be considered relative to diagnosis. Working with Daryl on his level of acculturation, past and present experience with discrimination and ethnic identity, will be explored. As Daryl is only 24-years old, research on African American youth and substance use will be considered. “African

Americans adolescents show lower rates of using alcohol or illicit drugs than European Americans and Latino/Hispanic Americans at most age levels, although the gap is narrowing due to recent increases in marijuana use among younger African Americans” Sue, 2016. p. 348). Substance Use Disorder Daryl admits to drinking daily. At this point, the type of alcohol he drinks and quantity of his daily use needs to be examined as well as his reported 6-month daily use of marijuana. The severity of an alcohol use disorder and/or cannabis use disorder needs further diagnostic clarification.

Substance Induced Disorder

It has been reported that some individuals develop chronic psychotic symptoms or schizophrenia following cannabis use (Sue, 2016). Alcohol induced psychosis will also be considered in regard to his delusions and hallucinations (APA, 2013, p. 110). Given that Daryl’s psychotic symptoms reportedly began prior to his abuse of alcohol or marijuana, a substance induced mental disorder is ruled out. It is possible that Daryl is using alcohol and marijuana to self-medicate given his statement about his use of substances to shut out the evil forces.

Provisional Diagnosis for Daryl

Schizophrenia 295.90 (F20.9), First episode, currently in acute episode (APA, 2013)

Diagnostic Criteria

A. Delusions (possessed by evil spirits, evil presence outside, evil forces trying to persuade him to take his own life). Hallucinations (sees shadows outside, hearing someone else talking during session), Negative Symptoms (not able to make eye contact, monotone speech).

B. Decreased level of function (not working, living with parents, unable to leave the house, diminished social engagement).

C. Continuous symptoms from Criterion A past 6 months. Exacerbation of symptoms from Criterion A past 4 months.

D. Schizoaffective Disorder, depression and bipolar disorder ruled out. No symptoms of major depression or manic episodes present. Suicidal ideation appears to be driven by psychosis and is incongruent with stated beliefs.

E. Substance induced symptoms ruled out due to onset of disturbance. No medical condition known.

F. No history of autism spectrum disorder or childhood developmental disorder.


Cultural Considerations

Daryl is of African-American descent. Racism and discrimination are significant concerns within the African American community. “African American clients tend to prefer an egalitarian relationship, so it is critically important to answer questions, explain the counseling and assessment process, and enlist the client’s assistance in determining goals and treatment strategies. Prior experiences may render issues of trust very important. The counselor can deal with these issues by discussing them directly and by being open, authentic, and empathetic” (Sue & Sue, 2016, p. 472). This will be addressed with Daryl in the models of treatment discussed in a further section of this paper.

Legal and Ethical Issues Risk assessment and safety will be addressed at the onset of treatment. People with schizophrenia have an increased risk of suicide. About 5–6% of people with the disorder die by suicide. About 20% attempt suicide (SAMHSA, 2018). Due to the severity of Daryl’s intrusive, suicidal-based delusions and his use of substances, he, will be referred to a psychiatrist for a complete medical, psychiatric and substance use evaluation. He may require a higher level of care until he is stabilized in mood and thought. Inpatient treatment can be beneficial for individuals with schizophrenia to prevent self-destructive behavior (Sue, 2016).

Biological Model

Researchers have found that closer blood relatives of individuals diagnosed with schizophrenia run a greater risk of developing the disorder. Abnormalities in certain neurotransmitters including dopamine, serotonin, GABA, and glutamate have also been linked to schizophrenia. According to the dopamine hypothesis, schizophrenia may result from excess dopamine activity in certain areas of the brain (Sue, 2016). In accordance with the biological model, Daryl will be under the care of a psychiatrist for medication management. Conventional and atypical antipsychotics can effectively reduce the severity of the positive symptoms of schizophrenia, such as hallucinations, delusions, bizarre speech, and disordered thought.

The therapist will educate Daryl on the genetic predisposition he may have inherited from his grandmother and the biochemical component of his treatment. This may also help Daryl understand why he seeks substances to alleviate his delusional symptomology. It is common for people with schizophrenia to use marijuana (SAMHSA, 2018). Given potential mistrust and suspiciousness associated with both the diagnosis and culture, this open, honest and empathic approach may facilitate a willingness to be compliant with treatment and medication.

Cognitive-Behavioral Model Combined with medication management cognitive-behavior therapy (CBT) may help Daryl cope with psychotic symptomology. Research indicates that the use of CBT has shown a significant decrease in psychosis compared to those only being treated with medication alone. This model will help Daryl identify the beliefs and stressors that exacerbate his symptoms.

Collaboration is an important aspect of CBT. The therapist will invite Daryl to be an active participant in his treatment. Therapeutic trust is crucial given cultural implications of trust in the African-American community. It is important that he feel safe in discussing his fears and anxieties associated with his beliefs about evil forces and the messages to kill himself. Normalization of his experience given his diagnosis will be integrated to strengthen the therapeutic relationship. Perhaps Daryl and the therapist could explore the meaning these symptoms have and creatively replace them with more adaptive coping skills. Decreasing the severity of his reaction to his intrusive ideation with alternative reactions may decrease their intensity and presence. Recovery, hope and resiliency and a non-critical focus on his delusional beliefs, the role his use of substances may play in exacerbation of his psychosis and a compassionate understanding of why he chose to use them could solidify the therapeutic alliance and foundation of healing.

Daryl’s use of substances will be considered in treatment. He claims to currently drink

alcohol and smoke marijuana daily, and has tried cocaine. Referral to dual diagnosis recovery

based group will be considered. Peer support services can foster hope, aid recovery and promote

resiliency (SAMHSA, 2018).


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Washington, DC:

Substance Abuse and Mental Health Services Administration. Behavioral Health Treatment and

Services. Treatment for Mental Disorders. Schizophrenia. (2018, April 6). Schizophrenia.

Retrieved from:

Sue, D., Sue, D. S., Sue, D., & Sue, S. (2016).   Understanding Abnormal

Behavior.   (11 ed).   Stamford, CT:   Cengage. ISBN: 978-1305088061

Sue, D.S & Sue, D. (2016). Counseling the Culturally Diverse: Theory and Practice. (7th ed).

Hoboken, NJ: John Wiley & Sons. ISBN: 9781119084303

Case of Daryl

Daryl, 24-year old male of African-American descent, presents in this first intake session. He tells you his thinks he is possessed by evil spirits. He sought help from his minister who in turn referred him for counseling. Daryl is cooperative during this intake session, though he is unable to make eye contact and is monotone in speech. A few times during the session, Daryl asks you to repeat what you said because he thought someone else was talking.

Daryl describes his childhood as “good”, with 2 loving parents, a younger sister and younger brother. His father is an attorney and his mother an RN. His sister and brother are both away in graduate school. His paternal grandfather died of cirrhosis of a liver due to heavy drinking. His maternal grandmother has been institutionalized for the past 40 years. Daryl never met her but was told she is schizophrenic and manic-depressive.

Daryl is currently unemployed and is living with his parents. He describes himself as a loner and spends most of his time playing video games. He does have one male best friend that he has known since childhood, and a girlfriend he has dated on and off since high school. Lately, he is afraid to leave the house because he sees shadows outside that he believes are of evil presence.

Daryl reports that approximately one year ago, he began to suspect that evil forces were trying to persuade him to take his own life. He was able to shake this off until 4-months ago when the intensity of these intrusive thoughts increased. He claims to have never been suicidal nor had any self-destructive thoughts. “It’s like this came out of nowhere. I was playing one of my video games and I suddenly felt possessed and the idea popped into my head that I should kill myself. I have no desire or plan to follow through but this scared me. I told my parents who took me to see our minister. That’s how I got to you”

Daryl does admit that his drinking has increased over the past 4 months and that he finds himself secretly drinking at home daily. He also admits that about 2-months ago, he began smoking marijuana daily and has tried cocaine. He believes his use of substances is to shut out the evil forces.


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