AKA Jessica Jones & PTSD

PSYCHOLOGICAL REPORT

Name: Jessica Jones
Date of Birth into Comics: November, 2001
Education: High school diploma
Date of Initial Interview: 11/20/2015
Date of Report: 10/01/2016
Therapists: Katie Gordon, Ph.D., Brandon T. Saxton, M.S.

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Presenting Problems:
Jessica Jones was referred for a psychological evaluation by her sister, Patricia “Trish” Walker. Trish was concerned that Jessica was experiencing negative effects from the multiple traumatic events that had occurred throughout her life, including developing a drinking problem to cope with trauma-related stress. Trish expressed a belief that Jessica’s life would be much better if she received treatment, despite Jessica denying experiencing any problems at all. Jessica presented as very resistant for this interview, calling us “a#$holes” and maintaining that she would not waste her time whining to therapists.

Family/Social History:
Jessica Jones was the only daughter of Brian and Alisa Jones. She grew up with her parents and younger brother, Philip. Jessica was not a very social young woman, preferring to spend time alone and often expressing annoyance at others. Tragically, Jessica’s family was killed in a car accident. Jessica recalled that the accident was caused by her father’s distraction as she and her brother were fighting. It was clear that Jessica still blamed herself for this event.

After the death of her family, Jessica was adopted by Dorothy Walker, a talent agent. According to Jessica, Dorothy only adopted her as a publicity stunt to promote her daughter’s television show. Jessica’s new family and home life came with turmoil. Jessica would often overhear the Walkers fighting over Trish’s television show. Jessica stated that Dorothy put the show’s success above all else. She recalled seeing bruises on her sister’s neck, which she suspected were inflicted by Dorothy.

At one point, Jessica found Dorothy forcing Trish to vomit into a toilet in an attempt to make her lose weight. Jessica used her incredible strength to throw Dorothy across the room. Dorothy fled in terror, and this sparked the beginning of a closer friendship between the sisters.

Later in Jessica’s life, while toying with the idea of becoming a superhero, she met a man named Kevin Thompson, better known as Kilgrave. Kilgrave was experimented on as a child by his parents. They were hoping to treat his neurodegenerative disease but ended up giving him the ability to control people’s minds. He met and became fascinated with Jessica when he witnessed her overpowering some criminals to prevent a mugging.

Jessica spent the next few months under Kilgrave’s mind control. They stayed together in a motel room, and he commanded her to tell Trish that everything was fine whenever she would check on Jessica. Kilgrave felt that they were in an actual relationship, but Jessica identified the traumatic time as his forcing her to be with him with his power of controlling people. At one point, when Jessica had a few moments of free will, she contemplated jumping off of a building. Kilgrave found her and ordered her to step down from the ledge.

Later on, Kilgrave was trying to obtain a flash drive that contained evidence of his parents trying to treat his neurogenerative disease through experimental and painful methods. Kilgrave discovered that a woman had buried the flash drive under concrete. He commanded Jessica to dig it up, which took hours. Then, Kilgrave commanded Jessica to kill the woman. She punched her so hard in the chest that her heart stopped. Jessica stated that, after killing the woman, she was so distraught, she actually walked away from Kilgrave. While walking away, Kilgrave was screaming for her to come back, and he was hit by a bus. This ended his control over her. Jessica believed he was dead.

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Educational/Employment History:
Following high school, Jessica worked a few different jobs. The first was in an office. Jessica hated the position, stating that “This job was sucking my brains out through the air vent.” After a few weeks there, Jessica used her investigation skills to blackmail her boss. He was committing fraud, and Jessica leveraged this information into a six-month severance package in addition to a letter of recommendation.

Jessica’s next job was working at a sandwich shop. She wore a sandwich costume, handed out fliers, and hated the job. While passing out fliers on the street, Jessica saw a young girl run into the road. Springing into action, Jessica was able to use her powers to save the girl from being hit by a taxi. Hearing the gratitude in the girl’s voice, in addition to the urging of her sister, Jessica actually considered using her powers to become a superhero.

Ultimately, after the events involving Kilgrave, Jessica gave up on the notion of becoming a hero. Instead, she opened a private investigation firm called Alias Investigations. Jessica’s work at Alias often involved being hired by people who thought their romantic partners were having affairs, and she also helped locate missing people.

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Psychiatric/Medical History:
Jessica reported experiencing some prior psychiatric treatment from a therapist who taught her to recite her childhood neighborhood street names when experiencing posttraumatic stress disorder (PTSD) symptoms. She had a negative view of mental health services, reporting that her previous therapist was a “quack,” saying that she did not want to join a “group of whiners,” and “screw therapy.” Jessica also once had a physician prescribe her antipsychotic medications, claiming that she was paranoid. Another person stated that Jessica was “coming across as distinctly paranoid,” to which she responded, “Everyone keeps saying that. It’s like a conspiracy.” However, the physician and other person were incorrect in their assumptions about her being paranoid, because Jessica was, in fact, being stalked by Kilgrave. Beyond obtaining super-strength, near invulnerability, and remarkable jumping ability while hospitalized following her family’s car accident, Jessica denied any other significant medical history.

Assessment & Diagnostic Impressions:
All assessment information was gathered through behavioral observations (i.e., watching Jessica Jones on Netflix). Jessica’s symptoms were best captured by two diagnoses featured in the Diagnostic and Statistical Manual of Mental Disorders-5th Edition (DSM-5): PTSD and alcohol use disorder.

As mentioned above, Jessica directly experienced multiple traumatic events (defined by the DSM-5 as exposure to actual or threatened death, serious injury, or sexual violence). Jessica’s PTSD symptoms mostly related to her traumatic experiences with Kilgrave, which included rape, emotional abuse, and being subject to extremely controlling and manipulative behavior. For example, Jessica appeared to experience multiple intrusive symptoms, such as nightmares (e.g., she woke up crying after dreaming that Kilgrave licked her face) and flashbacks (e.g., she felt as if Kilgrave was talking to her, which led her to burst into tears). Jessica also exhibited avoidance of situations that reminded her of the traumatic events (e.g., veered away from talking or thinking about what happened, consumed large quantities of alcohol to cope with trauma-related thoughts). When a friend suggested that she talk about her traumatic experiences, Jessica responded, “I prefer repression.” The friend added, “And self-medication,” referring to her frequent alcohol use. Additionally, she appeared to have negative changes to her thoughts and moods including distorted beliefs about herself and others (e.g., isolated herself from people due to self-blame for what she did under Kilgrave’s control). For example, a neighbor commented that she used sarcasm to distance herself from people and another neighbor stated that Jessica picked apart other people’s happiness because she was all alone (to which Jessica responded, “You are a very perceptive asshole!”). Jessica also told her sister, “I’m life-threatening, Trish. Stay clear of me.” Consistent with this pattern, Jessica tried to push Luke Cage away early in their budding romantic relationship. Finally, Jessica suffered changes in her arousal and reactivity (e.g., irritable mood, angry outbursts, reckless behavior including drinking alcohol to the point of being kicked out of a bar). A lawyer who she worked with described Jessica as “erratic” and “volatile.” When the same lawyer suggested that Kilgrave’s powers might be used for good, Jessica reacted by shattering glass with her fist. Jessica’s response to someone suggesting that she get a massage for stress reduction was, “Massages make me tense,” which is an atypical reaction to massages and may potentially be related to altered reactivity following her traumatic experiences (though this is speculative).

The DSM-5 defines alcohol use disorder as “a problematic pattern of alcohol use leading to significant impairment or distress, as manifested by at least two” of eleven symptoms. Jessica appeared to experience the following symptoms of alcohol use disorder: spending a significant amount of time using and recovering from alcohol (Jessica is shown drinking frequently throughout the day) and cravings to use alcohol (this was especially apparent when Jessica experienced elevated stress levels). It is difficult to assess the presence of some of the other alcohol use disorder symptoms based on the series, but it seemed possible that Jessica also developed some tolerance due to her frequent drinking and may have used alcohol in situations where it was dangerous to do so. Moreover, multiple people commented on her excessive drinking. Trish stated that she had alcoholism, and Kilgrave asked if she thought she drank too much (to which she replied, “It’s the only way I get through my day after how you treated me.”

Treatment Recommendations:
In summary, Jessica appeared to meet full diagnostic criteria for PTSD and alcohol use disorder. Well-established treatments exist for both disorders. Evidence-based treatments for PTSD include therapist-guided processing of traumas (e.g., Cognitive Processing Therapy, Prolonged Exposure) and decreasing unhealthy behavioral patterns without focusing directly on the traumas (e.g., Present-Centered Therapy). With regard to alcohol use disorder, research suggests that multiple types of treatment (e.g., Motivational Enhancement Therapy, which aims to strengthen desire and ability to decrease substance use) are most effective. Finally, Seeking Safety may be an appropriate choice for Jessica, because it is a research-supported treatment specifically designed for individuals struggling with comorbid PTSD and substance use problems. Seeking Safety includes teaching healthy coping strategies and skills to clients, so that they find safety in their relationships, feelings, and thoughts.

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THE GORDON/SAXTON TEST

1. Was the portrayal of mental illness accurate?

The portrayal of mental health problems in Jessica Jones was among the most accurate depictions we’ve seen. It’s rare for works of fiction to clearly identify mental disorders, and PTSD was specifically named as Jessica’s primary mental health problem in the series. Moreover, Jessica exhibited multiple DSM-5 PTSD symptoms, as well as associated distress and impairment, realistically across episodes. Finally, individuals with PTSD are at elevated risk for substance use disorders, and the series realistically displayed Jessica excessively using alcohol in an attempt to reduce the emotional pain she was experiencing.

2. Was the character struggling with mental health issues depicted with compassion?

The series reveals the events leading up to Jessica’s mental health problems in a manner that compels viewers to sympathize with her struggles. The writing and storytelling are superb, and Krysten Ritter is a phenomenal actress. Her portrayal of Jessica reflected a nuanced and complex understanding of PTSD. We believe that the series has the potential to help raise awareness about PTSD to broad audiences, which will hopefully lead to greater empathy for those suffering from it.

Overall rating:
On a scale of be-cool-and-just-watch-one-episode-per-day to RESISTANCE-IS-FUTILE-JUST-SURRENDER-TO-THE-BINGE-WATCH, we rate the depiction of mental health issues in Jessica Jones as RESISTANCE-IS-FUTILE-JUST-SURRENDER-TO-THE-BINGE-WATCH!

For more information on PTSD, please visit the National Center for PTSD website by clicking here.

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Diagnostics with Dwight

PSYCHOLOGICAL REPORT

Name: Dwight Kurt Schrute III
Date of Birth: January 20, 1968
Ethnicity/Race: Caucasian
Education: High school diploma
Employment:  Assistant to the Regional Manager, Dunder Mifflin, Scranton (past)
Paper Salesman, Staples (past)
Beet Farmer, Schrute Farms (current)
Regional Manager, Dunder Mifflin, Scranton (current)
Date of Initial Interview: 09/23/2010
Date of Report: 05/16/2013
Therapists: Brandon Saxton, M.S., Katie Gordon, Ph.D.

Presenting Problem
Dwight Schrute presented as a 42-year-old male who was referred by his boss, Michael Scott, via the Dunder Mifflin Paper Company. Michael had some concerns that Dwight was “kind of weird” and seemed to “not get along with others.” We’re not sure of the scientific validity of that assessment, so we decided to continue with an assessment of our own. Behavioral symptoms seem to include a variety of interpersonal conflicts that have influenced Dwight socially and vocationally.

Social/Family History
Dwight comes from a large and eccentric family. He recalls his own birth, stating specifically that his father, Cody Schrute, removed him from the womb and his mother bit off the umbilical cord. Dwight has one brother and one sister. Beyond that, he stated that he also had a twin in the womb, but he “reabsorbed” his twin giving him “the strength of a grown man and a little baby.” Dwight was born weighing 13 pounds and five ounces and performed his own circumcision. Growing up, Dwight reports that, as per family tradition, the youngest child raised the other children.

Dwight did not seem to want to spend much time describing his childhood. He did mention that he was shunned by his family from approximately age four through age six after he failed to save the extra oil from a can of tuna. He also reported losing an elementary school spelling bee by misspelling the word “failure.” This writer wonders whether these negative events created an avoidance in Dwight when it came to discussing his childhood. At any rate, Dwight was quick to begin describing his life as an adult and time working at Dunder Mifflin.

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Currently Dwight lives in a nine-bedroom, one-bathroom home located on a 60 acre beet farm that he inherited from his family. Dwight currently lives with his cousin Mose. Beyond growing beets on their farm, they also operate a small bed and breakfast and host events including weddings and garden parties. Currently, Dwight is employed as Assistant Regional Manager (it should be noted that his boss, Michael Scott, clarified that Dwight’s actual title is Assistant to the Regional Manager) at the Dunder Mifflin Paper Company. Dwight has been employed with Dunder Mifflin for several years and is considered one of the top sales staff in the company.

Interpersonally, Dwight seems to have a higher than average amount of conflict with his coworkers. This information was primarily obtained through collateral sources (i.e., Dwight’s coworkers and his personnel file). When asked about some, or most, of these incidents, Dwight seemed to not understand why his coworkers reacted the way that they did. A select list of these conflicts follows (for a more thorough review of these conflicts, please consult the large, surprisingly full, manila folder next to Dwight’s medical file). In one instance, Dwight attempted to test his coworkers’ emergency preparedness by locking them all in the office, simulating a fire, and yelling commands to them through a microphone. His coworker, Stanley, had a heart attack. During a subsequent CPR training, Dwight cut the face off the CPR dummy and wore it a la Silence of the Lambs.

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In another instance, Dwight tricked his coworker Phyllis into coming with him on a sales call. He actually drove her to a bad part of town, took her phone and wallet, and left her to walk home. He did this to help his branch win a corporate weight loss competition by forcing her to exercise. A final example included Dwight asking his coworker, Stanley, to join him on a sales call. Stanley declined. As such, Dwight shot Stanley with a bull tranquilizer, wrapped him in bubble wrap, slid him down the stairs, and loaded him into the car. Dwight then took Stanley, unconscious, with him on the sales call. These three examples are a fairly representative example of the types of behaviors in which Dwight engages at his workplace.

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Psychiatric/Medical History
Dwight has not received any formal psychological assessment or treatment. Despite this, there is some indication that he may have suffered from mental health symptoms in the past. For example, in episode 6.12, “Secret Santa,” Dwight says “… I’m just tired. The days are short. I don’t know. Maybe I’m depressed.” In addition, in episode 9.5, “Here Comes Treble,” Dwight says “You don’t think I have anxiety? I have anxiety all the time. Every waking moment of my life is sheer torture.” Taken together, these quotes suggest that Dwight may have previously struggled with an undiagnosed mood or anxiety disorder.

Diagnostic Impressions
All diagnostic assessment information was obtained through an interview with Dwight, his manager, and his workers. Beyond that, we reviewed his HR personnel file (i.e., we watched every episode of The Office. Multiple times). Based on the client’s history and presenting problems, diagnoses related to Cluster B and Cluster C personality disorders were considered. Diagnoses related to depressive and anxiety disorders were not further considered, as the symptoms related to each appeared very brief and not distressing.

A diagnosis related to Cluster B personality disorders, specifically a Narcissistic Personality Disorder, was considered. Dwight only meets the requirement for two of the five or more symptoms required to make the diagnosis. Dwight does exhibit a “grand sense of self-importance.” One example of this behavior in the way in which Dwight persists in calling himself Assistant Regional Manager as opposed to Assistant to the Regional Manager (much to the chagrin of his boss). Dwight also exhibits “arrogant, haughty behaviors or attitudes.” This seems to occur quite often, with Dwight often commenting on how he is a better salesman than his coworkers.

When fully considered, the symptoms that Dwight Schrute is experiencing are best captured by an obsessive-compulsive personality disorder. He exhibits 1) an excessive devotion to work and productivity to the exclusion of leisure activities and friendships (Dwight once comments on a sale that he never takes vacations, sick days, nor celebrates any major holidays – a pattern of behavior that is reinforced when he is named Northeastern Pennsylvania Salesman of the Year), 2) is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (Dwight allows himself to be fired to respect his girlfriend, Angela’s, prioritization of privacy in the office; he instigates a formal investigation, including drug testing of every employee of the office, after finding a small amount of marijuana in the parking lot; he goes to excessive lengths to act consistently with his highest personal value, which is respect for authority and hierarchical systems), 3) is reluctant to delegate tasks or to work with others unless they submit to exactly his way of doing thinks (do we need to explain this one?? If you’ve watched the show, you’ve seen this!), 4) shows rigidity and stubbornness (Dwight trying to impress a manager for a promotion despite experiencing acute appendicitis and consistently refuses any flexibility in his actions despite extremely reasonable requests from his coworkers).

 Treatment Recommendations
Currently, there are not any well-established treatments for obsessive-compulsive personality disorder that have been tested in large randomized clinical trials (the gold-standard for testing what treatments work best!) It is worth noting that obsessive-compulsive personality disorder is different from obsessive-compulsive disorder, which is a disorder that does have clear evidence-based treatment for it. Approaches that have been used effectively include cognitive therapy, which focuses on challenging maladaptive thoughts related to the disorder. It’s possible that Dwight developed his personality characteristics as a consequence of being raised according the Schrute Family Rules (as Dwight reports, “Schrute boys must learn 40 rules before the age of five. They are told that if they don’t learn their rules, they will be eaten in their sleep.”) Dwight would likely benefit from therapy focused on flexibility and balance to decrease his rigidity with this rule-set.

Status at Termination (last episode)
Sometime later, Dwight returned to our office for a booster session, although this writer wonders whether the session was necessary. It seemed, perhaps, that Dwight more so wanted to share with us his new station in life. He reported having finally achieved the position of Regional Manager at the Dunder Mifflin Scranton office. Dwight reported that he is currently happily married to Angela. The two of them, and their son, Philip, live at Schrute Farms. In addition, Dwight reported that his relationships with this subordinates (yes, he did use that term) had improved dramatically. He said he now considered them all friends (despite firing Kevin Malone). All in all, it seemed that Dwight had experienced significant symptom reduction and was operating and feeling much happier in life.

The Office - Season 9

THE GORDON/SAXTON TEST

Was the portrayal of mental illness accurate?
Full disclosure: some of Dwight’s behaviors are exaggerated. And we’re thankful for it. He is easily one of our favorite fictional characters for this very reason. Despite this exaggeration, some of the behaviors that Dwight exhibits are not entirely out of the question. Oftentimes individuals who grow up in strict, rigid homes develop these characteristics themselves. This does not always lead to the formation of a mental health disorder, but in Dwight’s more extreme case, it certainly seemed to.

Was the character struggling with mental health issues depicted with compassion?
Overall, we do find the portrayal of Dwight to be a compassionate one. Yes, sometimes he is a nuisance to his coworkers. One could even argue that, at times, he is a danger to them! But overall, as the series progresses we see Dwight develop and evolve into a really caring individual and a capable leader. This is the kind of progression that we hope to see with clients in therapy, so seeing it in one of our favorite fictional characters just seems right.

Overall rating:
Overall, from a rating scale from Toby (yuck) to Dwight (oh, yeah!), we would rate the portrayal of Dwight as Dwight K. Schrute, Manager! The Office is one of our favorite shows and Dwight is a main reason for that. He starts off as a rough-around-the-edges kind of person. Throughout the nine seasons, we see him experience a lot and grow into a really lovable character. By the end, Dwight gets along well with his coworkers, has a family, and finally leads the branch!

Gaming Disorder in The Guild

PSYCHOLOGICAL REPORT

Name: Cyd Sherman AKA Codex
Employment: Violinist through ~2006, Unemployed ~2007-2012, Vice-President of Community Creative Consultancy, The Game ~2012-present
Date of Initial Interview: July 27, 2007
Date of Report: January 8, 2013
Therapists: Katie Gordon, Brandon Saxton

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Presenting Problem
Cyd Sherman presented as a single, casually-dressed woman in her twenties. She walked in, lied down on the couch, and explained that she had been dealing with symptoms of depression and anxiety. She also reluctantly admitted that the significant amount of time that she devoted to playing a massively multiplayer online role-playing game (MMORPG) could be contributing to some of her problems (e.g., not seeking out new employment, having few social contacts IRL). Recently, her life had taken a turn for the worse when her therapist, Dr. Hammond, “broke up” with her. When asked to elaborate, Cyd explained that Dr. Hammond “fired” her saying, “You can’t grow if you are still immersed in an imaginary social environment.” Cyd then asked if it was “even medically legal” for her therapist to discontinue treatment.

History
Cyd disclosed that her father “made her” see a therapist due to his concerns about her being depressed. When she started seeing Dr. Hammond for treatment, she was employed in an orchestra, “I’m a violinist. You know, former child prodigy…now I’m old,” and she was dating a man named Trevor. Life started to go downhill when Trevor manipulated Cyd into writing his band’s songs without giving her any credit and generally treating her poorly. The last straw was when she caught him cheating on her with the first chair oboist, Günther. In response, she burned pages of Trevor’s band’s songs and inadvertently created a fire that destroyed his $100,000 cello. Consequently, she was fired from the orchestra because of concerns about her burning a musical instrument. Cyd actually felt better initially because her unemployment allowed her more time to spend with her gaming guild playing the MMORG (The Game). However, she ultimately chose to seek help for her gaming because of financial concerns related to unemployment (e.g., maxing out credit cards, subsisting on Ramen), as well as distress related to feeling rejected by her last therapist.

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Diagnostic Impressions
All assessment information was obtained through reading The Guild comics, watching the web series (available on youtube and Netflix!), and music videos. First, due to the nature of referral, Cyd was evaluated for disorders related to her internet gaming. According to the Conditions for Further Study section in the appendix of the DSM-5 (reserved for disorders requiring additional research and not yet considered officially included), internet gaming disorder is defined as “persistent and recurrent use of the internet to engage in games, often with other players, leading to clinically significant impairment or distress as indicated by 5 (or more) symptoms in a 12-month period.” Cyd clearly exhibited at least 6 of the 9 symptoms:

1) Preoccupation with internet games

Cyd characterized her time spent playing The Game as taking “5…8…9 hours a day.” When she decided to meet up with her fellow guild members in person, they struggled to talk about anything other than The Game. At one point, there was a threat of The Game being sold to a new owner and Cyd responded with, “This game is my life,” and “My life is empty. What will I do without the game?” Her preoccupation was also apparent when she introduced herself to her neighbor as Codex (her avatar’s name).

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2) Withdrawal symptoms when internet gaming is taken away

When The Game was shut down for four hours for a server update, Cyd and her fellow guildies treated it as a crisis situation. Cyd also panicked another time when her computer stopped working. She hit a fellow guild member (Bladezz), started crying, and said, “I’m so stressed right now. I need to have a computer for The Game…for living.” In desperation, she took a job without pay at Cheesybeard’s (a restaurant) simply so that she would have access to a computer and the internet.

3) Unsuccessful attempts to control the participation in internet games

This is a post-it note on Cyd’s computer:

post-it4) Has deceived family members, therapists, or others regarding the amount of internet gaming

Cyd told her therapist, “I’m setting parameters. Kind of,” when she was failing to keep to agreed-upon limits. Cyd could not even stop playing The Game while talking to Dr. Hammond on the phone about her excessive gaming problem. She told her therapist, “You’re killing me…literally,” in reference to action in the game.

5) Use of internet games to escape or relieve a negative mood (e.g., feelings of helplessness, guilt, anxiety)

While upset about her ex-boyfriend cheating on her, Cyd decided to go on a “video-game bender.” She stocked up on energy drinks and played The Game from 7:42pm one night until she fell asleep at 11:14am the next morning. She also said, “I guess I can’t cope well with anything. In the game, at the end of the day, you can just log off. You can’t log off of your own life.”

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6) Has jeopardized or lost a significant relationship, job, or educational career opportunity because of participation in internet games

After being fired from the orchestra, Cyd reported that she was “still jobless, yay” and hadn’t left the house in a week. In fact, the first job she pursued was the aforementioned unpaid job at Cheesybeard’s. Her ex-boyfriend, Trevor, also claimed that he cheated on her with Günther because they “drifted apart” due to her use of video games. At a later point, when a romantic interest didn’t work out, she reacted with, “At least I don’t have to make room for dating around my gaming schedule.”

In addition to internet gaming disorder symptoms, Cyd reported a variety of different anxiety symptoms. For example, Cyd said that she felt squeamish, faint, and tended to vomit at the sight of “raw chicken liver, really bad acne, and people’s toe hair,” which may be indicative of an overactive anxiety response. Other examples of this tendency include having an “anxiety attack” while trying to convince a former guild member to come back to their guild (The Knights of Good) and a “panic attack” when trying to convince a man (Fawkes) to go out with her again. She also referred to herself as generally “neurotic” and provided examples: 1) “I always get everywhere a half hour early and spend a lot of time sitting in the car,” 2) she planned to keep her guild from finding out that she had a one night stand with a rival guild member from the Axis of Anarchy by “all night…obsessively” thinking about it, and 3) purposely having her character die while reading ‘choose your own adventure’ books because she couldn’t handle the stress of uncertainty.

Cyd also displayed significant social anxiety (or potentially avoidant personality disorder) symptoms. With regard to her youth, she said, “I was never the teacher’s pet. I specifically underperformed so that the teacher wouldn’t pay any attention to me whatsoever.” She also described feeling awkward and uncomfortable at parties and meeting strangers, and having significant anxiety when trying to contact a friend through a internet chat channel filled with people she didn’t know. Cyd showed insight about the incident saying, “Meta-social anxiety….that’s sad.” Perhaps in relation to her social anxiety, Cyd also struggled with assertiveness. For example, she had a hard time asking her Guild-mate, Zaboo, to leave her house when he showed up uninvited and moved in and also recalled, “One time I got caught holding the door open after an orchestra concert for 25 minutes, so I’m not really the best measure of assertiveness.”

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Finally, Cyd also appeared to be experiencing symptoms of depression. She pondered being rejected by the neighbor that she was romantically interested in, “What’s the worst that could happen? I would just cry a lot – which I’d do anyway,” and reported feeling depressed “always.”

Treatment Recommendations
In summary, Cyd appeared to meet full diagnostic criteria for internet gaming disorder. While not enough information was available to specifically determine if she met criteria for a current major depressive episode or which specific anxiety disorder(s) she would meet criteria for, it was clear that these symptoms negatively impacted her. Moreover, her anxiety and depression symptoms likely played a role in her internet gaming disorder. Therefore, it was recommended that she receive treatment for anxiety and depression along with specifically targeting her internet gaming disorder symptoms.

Currently, there are several well-established treatments for anxiety and depression that have been tested in rigorous scientific studies. These evidence-based approaches include strategies focused on changing thoughts and behaviors and increasing positive interpersonal interactions (e.g., via cognitive-behavioral therapy), as well as other treatment modalities.

With regard to Cyd’s internet gaming disorder, there is substantially less research on the condition and its treatment in light of its current status in the DSM as a disorder in need of further study. A recent review on available research on the topic found very few clinical trials available to guide treatment planning. Thus, a behavioral approach identifying and addressing the functions and situational triggers that maintain excessive internet gaming was recommended. In light of Cyd’s ambivalence about change (i.e., she both loves playing The Game and simultaneously is concerned about her excessive use), an approach focused on enhancing her motivation might also be appropriate. However, because these are not scientifically-tested and established approaches for internet gaming disorder (due to the recency of the proposed disorder), it would be particularly important for the therapist to closely monitor and assess the impact of the interventions and adjust them as needed (e.g., ceasing this approach if it causes harm).

Follow-Up Assessment
At follow up, Cyd exhibited significant improvement with regard to her depression and anxiety symptoms, as well as a reduction in distress and impairment related to internet gaming disorder. The most powerful component of this change was Cyd’s development of meaningful in-person friendships with her fellow guild members. Through her interactions with them, she faced and overcame her anxiety in pursuit of shared goals, which helped to strengthen her confidence and assertiveness, while decreasing her avoidant coping tendencies. In addition, she was able to gain employment and channel her passion for The Game through taking a paid position in their company.

THE GORDON/SAXTON TEST

  1. Was the portrayal of mental illness accurate?

Felicia Day is the creator, writer, and actress who portrayed Cyd in The Guild. She based Cyd’s anxiety, depression, and internet gaming disorder symptoms on her own experiences struggling with these issues and playing World of Warcraft. Overall, The Guild provided an accurate presentation of ways that these mental health issues can manifest.

    2. Was the character struggling with mental health issues depicted with compassion?

Yes, Cyd was portrayed as a sympathetic, humorous character. In addition, Felicia Day has helped to raise awareness and reduce stigma associated with these mental health issues by writing, in detail, about her experiences in her memoir You’re Never Weird on the Internet (Almost).

Overall rating
On a scale of n00b to MLG, we rate this depiction MLG!

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