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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Silent Bob’s Psyche

PSYCHOLOGICAL REPORT

Client Name: Silent Bob
Date and Location of Birth: 1970s-ish in New Jersey
Date of Initial Interview: January 19, 2006
Date of Report: July 21, 2006
Therapists: Katie Gordon, Brandon Saxton

Presenting Problem
Silent Bob presented as a man in his early 30s who was dressed in a backwards hat, long coat, and jeans. After we greeted him in the waiting room, he used charade-like behavior to ask if we would hold the session outside so that he could smoke cigarettes. After going to an outside area, he leaned against a wall, and continued to communicate mostly through emphatic facial expressions and gestures rather than speaking.

A review of Silent Bob’s paperwork indicated that he was court-ordered to treatment following charges of possession of marijuana with intent to sell. The police report stated that he and his friend, Jay, were driving around with a deployed airbag when a police officer pulled them over for “suspicion of mischief.” The police officer then searched their car and found two pounds of “Jamaican Landswolf” marijuana. The prosecutor wanted Jay and Silent Bob to be sentenced to prison for ten years, but the judge ordered them to complete drug rehabilitation instead.

Educational/Employment History
Silent Bob completed a minimum of eighth grade (when he won the science fair) and likely continued beyond that. However, details could not be confidently discerned from Silent Bob’s gestures. After completing school, he became a self-employed drug dealer with his best friend, Jay. He and Jay particularly enjoyed selling marijuana in front of a Quick Stop convenience store in New Jersey. Another source of income for Silent Bob was from a movie (Bluntman and Chronic) that was developed from a comic book starring a character based on him.

Psychosocial History
Little is known about Silent Bob’s family history and not much could be gleaned from his nonverbal behavior on this topic either. There was one mention of his mother, in that he won that eighth grade science fair by turning one of her personal belongings into a CD player through the use of chicken wire. For this accomplishment, his friend Jay referred to him as an “electrical genius” and “better than MacGyver.” He also reportedly had a cousin named Olaf from Moscow, Russia who was a metal singer.

In terms of significant romantic relationships, Silent Bob was in a relationship with a woman named Amy approximately ten years prior to the initial interview. In a rare moment of speech, he described them as “inseparable” and “big time in love.” Due to feelings of insecurity about her romantic past, he ended their relationship and deeply regretted it, saying that he “spent every day since then Chasing Amy…so to speak.”

With regard to friendships, Silent Bob spent most of his time with his best friend, Jay, ever since they met as young babies in strollers outside of the Quick Stop. Together, they spent the vast majority of their time loitering, smoking and selling marijuana, and beating up people who were critical of Bluntman and Chronic on the internet. True to his name, Bob was often silent while Jay regaled him and others with crass, colorful stories and commentary. They also enjoyed listening to music together and dancing while loitering. In fact, during one of the rare times when Silent Bob spoke, he revealed that he “always wanted to be a dancer in Vegas.” It should be noted that, as occasions arose to help others, Jay and Silent Bob often stepped up to the challenge. For example, they once helped their friends T.S. and Brodie reunite with their ex-girlfriends and, another time, they liberated animals from a testing facility. Remarkably, they also played important roles in preventing two fallen angels (Bartleby and Loki) from ending all of existence.

Diagnostic Impressions
All assessment information was obtained through behavioral observations and record review (i.e., watching, reading, and listening to ALL the Kevin Smith movies, books, and podcasts). First, due to the nature of the court-ordered referral, Silent Bob was evaluated for disorders related to his marijuana use. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), cannabis use disorder is defined as “a problematic pattern of cannabis use leading to significant impairment or distress, as manifested by at least two” of eleven specified symptoms (e.g., tolerance, withdrawal, repeated use in dangerous situations such as driving, repeated failed attempts to cease marijuana use). Due to the limited communication from Silent Bob during the assessment, we could not conclusively determine whether he met full criteria for this disorder. However, we speculated that he was likely to have met criteria for cannabis use disorder as evidenced by the following symptoms: 1) substantial time devoted to obtaining and using cannabis and 2) the presence of intense cravings to use cannabis. Moreover, he appeared to be experiencing associated impairment in light of his legal troubles.

Secondly, Silent Bob also appeared to meet criteria for a second disorder: selective mutism. He exhibited all of the DSM-5 criteria for selective mutism: 1) repeated failure to speak in social situations where one is expected to speak, despite speaking in other situations, 2) the disturbance interferes with social communication, 3) the duration is at least one month, 4) the failure to speak is not attributable to lack of knowledge of spoken language.

Treatment Recommendations
In summary, probable diagnoses for Silent Bob include cannabis use disorder and selective mutism. Currently, there are several well-established treatments for substance use disorders that have been tested in rigorous scientific studies. These evidence-based approaches include strategies focused on enhancing motivation for change (motivational interviewing, motivational enhancement therapy), identifying and changing thoughts and behaviors that contribute to the substance use problem (motivational enhancement therapy plus cognitive-behavioral therapy), and participation in a behavioral program that reinforces drug abstinence (prize-based contingency management).

With regard to Silent Bob’s selective mutism, existing scientific evidence points to cognitive-behavioral approaches as effective. These approaches teach individuals with the disorder skills for adaptively coping with and reducing the obstacles to their verbal communication, while behaviorally reinforcing them for communicating through spoken language.

Status at Follow-Up (Clerks II)
At a follow-up session six months and two days later, Silent Bob denied the presence of any cannabis use disorder symptoms. Through a series of questions that Silent Bob responded to with head nods, head shakes, gestures, and occasionally drawing pictures, we determined that he had maintained sobriety since our initial meeting. He attributed his marijuana abstinence to his enrollment in a six-month rehabilitation program that utilized the 12 Steps of Narcotics Anonymous. While Silent Bob should be commended for his dramatic behavioral change, there were several risk factors for relapse that were identified. First, his beloved Quick Stop convenience store had burned down. He was reportedly coping with this stressor by loitering in front of a fast-food restaurant (Mooby’s) instead. Secondly, though Jay was also sober, they both continued to sell marijuana. When asked how he would resist smoking marijuana while selling it, he pulled a bible out of his coat. Silent Bob had been raised Catholic and reconnected with Christianity during rehabilitation, which led him to feel that his spiritual connection would prevent a relapse. Nonetheless, it was strongly recommended that Silent Bob explore other occupations in order to reduce his chances of relapsing.

THE GORDON/SAXTON TEST

1. Was the portrayal of mental illness accurate?

Silent Bob is a comedic character that Kevin Smith created mainly so that the character, Jay, had someone on the receiving end of all of his funny behavior. Still, he does exhibit symptoms that are realistically consistent with cannabis use disorder, as outlined above. With regard to selective mutism, Silent Bob exhibits many of the actual symptoms of the disorder. However, it is worth noting that the disorder is extremely rare in adults and tends to occur in children. Moreover, it is likely that Silent Bob would speak more frequently to Jay in the context of their close friendship. In children with selective mutism, they often speak with their family members and sometimes close friends, but are silent in other settings (e.g., in school, with strangers).

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

As mentioned above, Kevin Smith was not specifically aiming to have Silent Bob represent a person suffering from mental health issues. However, Silent Bob is certainly a likable character. Furthermore, it is very clear from reading Kevin Smith’s books and listening to his podcasts that he has great compassion for his friends who have struggled with substance use and other mental health issues. He is openly supportive and helpful to his friends in real life, and in this way, he helps to reduce stigma surrounding these mental health issues.

Overall rating: On a scale of snoogans to snootchie bootchies, we rate this portrayal as snootch to the nootch!

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