Diagnosing The Dude

PSYCHOLOGICAL REPORT

Client Name: Jeffrey Lebowski, AKA The Dude, His Dudeness, Duder, or El Duderino (if                                         you’re not into the whole brevity thing)
Education: College
Occupation: Currently unemployed
Date of Birth: December 4, 1942
Date of Interview: March 6, 1998
Therapists: Katie Gordon, Brandon Saxton

Presenting Problem
Jeffrey “The Dude” Lebowski was referred for a psychological evaluation by his special lady friend, Maude Lebowski, who told him that we were good people “and thorough.” Once described as “quite possibly the laziest in Los Angeles County, which would place him high in the running for laziest worldwide,” The Dude presented as a 47-year-old man who was dressed casually in a lavender t-shirt, patterned pants, and jelly sandals. Right away, the mental status exam raised clinical concerns, as The Dude did not seem fully oriented to time, person, and place. When asked the date, The Dude responded with, “Is this a…what day is this?” and then asked, “Mind if I do a J?” When asked what his chief complaint was, The Dude explained that his rug had recently been destroyed by people who broke into his house. He appeared very distressed by this, and when asked why it was so bothersome to him, he replied that, “it really tied the room together.”

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History
Gathering a comprehensive history was challenging with The Dude. He reportedly attended college and spent most of his time there “occupying various administration buildings…smoking a lot of Thai stick…breaking into the ROTC…and bowling.” When asked about the type of degree he was pursuing, The Dude stated, “To tell you the truth, I don’t remember most of it.” In response to a question about the kind of work he did, The Dude said, “a little of this, a little of that.” He recalled being a roadie briefly for Metallica on the Speed of Sound tour. He remarked that they were “a bunch of assholes,” and also reported hating “the <expletive> Eagles, man.” Earlier in his life, The Dude engaged in some social activism, reporting that he was one of the Seattle Seven and contributed to the first draft of the Port Huron Statement. Lately, his career had reportedly “slowed down a bit,” such that he spent the majority of his time bowling, driving around, and having an “occasional acid flashback.” The Dude stated that he had friends who he spent time with, and in particular, someone named Walter who played in his bowling league (except on Shabbos). When asked about his marital status, The Dude replied, “Do you see a wedding ring on my finger? Does it look like I’m <expletive> married?”

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Diagnostic Impressions
All assessment information was obtained through observing The Dude in The Big Lebowski. In general, The Dude presented as a laidback, go-with-the-flow kind of guy who seemed generally happy with his life. Thus, we approached our diagnostic examination with an effort to not over-pathologize his eccentricities and stuck to exploring potential areas of distress and impairment. The Dude’s areas of distress included the loss of his rug and tense interactions with his friend, Walter (e.g., when Walter pulled a gun out during a bowling league game). Meanwhile, The Dude exhibited impairment in managing some of his responsibilities (e.g., failing to pay his rent on time, driving unsafely). For example, The Dude attempted to throw a joint out of a closed car window while driving, and it fell in his lap and burned him. He then poured the liquor he was drinking on it and crashed his car.

The possibility of adjustment disorder following the loss of The Dude’s rug was investigated. While The Dude’s emotional and behavioral reactions to the stressor (e.g., going to the real Jeffrey Lebowski’s house to demand a new rug) were a bit out of the norm, they did not cross the threshold into a pattern of clinically significant emotional problems that caused substantial impairment in important areas of functioning. Therefore, adjustment disorder was ultimately ruled out.

The full extent and range of The Dude’s alcohol and other substance use at the time of assessment was not totally clear, but he did mention at least some previous LSD use and tell Maude that he was “adhering to a pretty strict drug regimen to keep my (his) mind limber.” He appeared to, at a minimum, regularly smoke marijuana and drink White Russians. Due to the limited available information, we could not conclusively determine whether he met full criteria for alcohol use disorder. However, he likely met criteria for cannabis use disorder. 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, repeated failed attempts to quit using). He appeared to exhibit the following: 1) a great deal of time is spent in activities necessary to use cannabis 2) recurrent cannabis use in situations in which it is physically hazardous (e.g., driving), and 3) craving, or a strong desire or urge to use cannabis.

Treatment Recommendations
Overall, this is a very complicated case with a lot of ins, a lot of outs, and a lot of what-have-yous. However, the probable diagnosis for The Dude is cannabis use disorder. If The Dude decided to pursue treatment, 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 interviewingmotivational 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).

Status at Follow-Up 
The Dude abides.

THE GORDON/SAXTON TEST

Was the portrayal of mental illness accurate?
The Dude’s primary purpose as a fictional character is comedic in nature. Nonetheless, he does exhibit some symptoms that are realistically consistent with cannabis use disorder (as outlined above). Remarkably, his character was based on a real person who has striking similarities to the fictional Dude. Check out this video about the real Dude (Jeff Dowd), who views his fictional counterpart affectionately as a holy fool, which he defines as “one who subverts conformity in order to point to the truth in a funny way.”

Was the character struggling with mental health issues depicted with compassion?
Even though The Dude is fairly irresponsible during the time period depicted in the film, people seem to really like him, want to emulate aspects of his approach to life (e.g., some view it as consistent with Zen philosophy), and feel sympathy for the loss of his rug. Therefore, it seems reasonable to conclude that he is portrayed with some compassion…but, that’s just like our opinion, man.

Overall rating: On a scale of very Dude to very un-Dude, we rate this portrayal as calmer than you are!

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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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Diagnosing the Dark Knight

PSYCHOLOGICAL REPORT

Name:  Bruce Wayne, aka Batman
Date of Birth: February 19th
Age: 30 – 32 years of age (in the current Batman comics)
Ethnicity/Race: Caucasian
Education: Degrees in Criminal Science, Forensics, Computer Science, Chemistry, Engineering, Biology, Physics, Advanced Chemistry, and Technology
Date of Initial Interview: 3/01/2016
Date of Report: 3/24/2016
Therapists: Brandon Saxton, Kathryn Gordon

Presenting Problem
Bruce Wayne (Batman) presented as an approximately 30- to 32-year-old man, who was referred for treatment by his former guardian and current butler, Alfred Pennyworth. Alfred primarily had concerns related to the traumatic loss of Bruce’s parents at a young age and the obsessive and unrelenting way that he wages war on the criminals of Gotham City which has resulted in significant distress, physical harm, and in some cases death to his family, co-workers and the individuals he apprehends.

History
Bruce Wayne was born on February 19th in Gotham City. Bruce was the only child of Thomas and Martha Wayne. In addition to his medical career, Thomas and his wife, Martha, owned Wayne Enterprises and were both dedicated philanthropists. They were both heavily involved in efforts to restore Gotham City which was battling a depression, rising crime rates and corruptions, and overall despair. Overall, Bruce reported mostly positive memories regarding his childhood, during which he lived with his parents and butler at Wayne Manor. Bruce identified two traumatic childhood events that helped to shape him into who he is today. The first occurred when he was very young and playing on the grounds surrounding Wayne Manor. While playing, he fell through a hole in the ground that dropped him into a cave system that ran under Wayne Manor. Unfortunately for young Bruce, the cave system was home to hundreds of bats. He reported that this instilled in him a strong fear of bats. Subsequently, he reported seeing one uniquely large bat from the cave system multiple times following the event.

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The second traumatic event that Bruce reported occurred a while after when he fell into the cave system. Bruce, along with his parents, attended the film The Mask of Zorro. As they were leaving the theater, the Wayne family was confronted by a mugger demanding their valuables. Thomas resisted the mugger which resulted in both he and Martha being shot and killed. Bruce was left alone with the dead bodies of his parents. Bruce identified this as being the most traumatic and defining moment of his life. With the passing of Bruce’s parents, Alfred, the family butler, became his guardian and caretaker. While processing his parents’ murder, Bruce reported experiencing a great deal of distress. At the peak of this transformative process, Bruce recalled finding himself standing in front of the graves of his parents. It was then and there that he vowed to get vengeance for what happened to his parents and to keep that from happening to anyone else ever again. Bruce reported that this was the moment where, in his mind, Bruce Wayne died, and Batman was born.

Holding true to the promise he made at the graves of his parents, Bruce threw himself into his schoolwork. He was very successful and reported performing at the top of his class. After graduating high school, Bruce left the country to travel the world training under a variety of martial arts masters. He sought out the best of each discipline to train under. When he felt prepared, he returned to Gotham City to begin his crusade against the criminal underworld. Bruce started off small by simply patrolling the more dangerous areas of Gotham City on foot. His goal was singular; to learn more about the criminals that ran Gotham City. Unfortunately, one night Bruce was attacked and involved in a street brawl. As a result of the fight, he was seriously injured. Bruce was fortunate enough to make it back to Wayne Manor safely and without being identified. Bloody, broken, and seemingly defeated, Bruce recalled sitting in his father’s study. Contemplating what went wrong, he realized that criminals, although cowardly and superstitious, would never fear a common, unarmed man on the street. At that moment, the large bat he had reported seeing previously made its return. The bat smashed through the window into the study. Though nearing unconsciousness, due to blood loss — the answer was obvious to Bruce. He would become the thing he feared most, a bat.

With the help of Alfred, Bruce worked tirelessly to design a functional, yet frightening suit, weaponry, and base of operations for the Batman. Ultimately, Bruce settled on the cave system under Wayne Manor which he coined “the Batcave.” Bruce reported that he grew quickly as the Batman. As he combined experience to his years of training, he become much more effective and competent. The police force, ripe with corruption, demonized and hunted him. However, there was one officer, James Gordon, who held out against the corruption. After some time, Batman and James Gordon began what would be a long-term professional partnership. As Batman gained more notoriety, the villains he faced evolved from common criminals to supervillains. Bruce reported that some of the more fearsome foes he faced included Edward Nygma, known as The Riddler, Oswald Cobblepot, known as The Penguin, Harvey Dent, known as Two-Face, Pamela Isley, known as Poison Ivy, Dr. Jonathan Crane, known as Scarecrow, and perhaps most fearsome of all, the Joker, whose identity is yet unknown. As the criminals of Gotham City evolved, Batman knew he had to as well.

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To ramp up his war on crime, Batman decided to take a sidekick. Dick Grayson, known at the time as Robin, joined Batman. For quite some time, the two worked well together in what was a major change in the way Batman, who was used to operating alone, battled crime. However, as the criminals became more dangerous, Bruce decided he did not want to place Robin in more danger than was necessary. As such, Batman started to keep Robin on the sidelines. Eventually, the two split, with Dick Grayson taking up the mantle of Nightwing and leaving to operate independently of Batman. Sometime later, Batman took his second Robin, Jason Todd. Todd was a young man whose parents were killed by Two-Face. Bruce reported empathizing with Todd’s experience and wanting to help guide the young man down a path where he could channel his emotional responses for good. Despite this, Todd was much more rebellious and angry in his approach to crime fighting than Dick Grayson was before him. One night, while working solo, Jason Todd was taken, tortured, and killed by the Joker.

Bruce reported that the loss of Jason Todd hit him hard. He returned to fighting crime alone as a much darker force than he ever had been before. This new, darker, less refined Batman was noticed by a young boy named Tim Drake. Tim, an extremely bright young man, was able to work out the identity of Batman and the original Robin, Dick Grayson. He urged Dick Grayson to return to his role as Robin, as he felt that Batman needed someone to stabilize and support him again. Dick Grayson refused to return as Batman’s sidekick. However, through this pursuit, Tim Drake himself ended up becoming the third Robin. Bruce reported refusing to make the same mistake again and insisted that Tim train with the individuals from whom Bruce learned. As a result, Tim was a Robin who was much closer in ability to Batman himself.

Bruce then reported what he identified as the most challenging moment of his career, a time where he was not able to wear the cape and cowl. This period of time was the result of Batman battling and ultimately being defeated by the criminal known as Bane. Bane was able to defeat Batman, physically overpowering him and breaking his spine. While Bruce recovered, one-time villain, Azrael, took the mantel of the Bat. Azrael proved a poor Batman though, becoming so unstable that he was eventually close to executing criminals. Bruce was able to recover and defeat Azrael to reclaim the cowl.

Tim Drake moved onto a new, more independent role as Red Robin. Meanwhile, Bruce’s son, which he didn’t know he had, Damian Wayne, stepped into the role as the next Robin. Damian’s mother was Talia al Ghul, the daughter of Ra’s al Ghul, leader of the League of Assassins. As such, Damian received training from the league and was exceptionally skilled. Bruce, however, clashed with his son’s assassin training and reported trying his best to instill in him the values he had gotten from his parents. However, in an event outside of his control, Damian was killed battling an adult clone of himself known as The Heretic. Bruce reported that this event would have ended him without the support of the Bat-family and Alfred.

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Assessment & Diagnostic Impressions
All diagnostic assessment information was obtained through this interview and behavioral observation (i.e., Batman comics, television shows, and movies). Based on the client’s history and presenting problems, diagnoses related to posttraumatic stress disorder, cluster B personality disorders, and cluster C personality disorders were considered. Bruce does exhibit some symptoms related to posttraumatic stress disorder. Specifically, he met the following criteria: 1) exposure to actual of threatened death, serious injury, or sexual violence (the murder of his parents), 2) presence of intrusion symptoms associated with the traumatic event, beginning after the traumatic event(s) occurred (Bruce experiences repeated distressing memories, dreams, flashbacks, and distress at symbols of the death of his parents), and 3) marked alterations in arousal and reactivity associated with the traumatic event, beginning or worsening after the traumatic event occurred (the war Bruce wages on Gotham could be defined as reckless or self-destructive behavior with elements of hypervigilance). Ultimately, a diagnosis of posttraumatic stress disorder was ruled out because Bruce does not meet all of the required criteria, specifically avoidance of stimuli associated with the traumatic event, as evidenced by his being the Batman.

A diagnosis related to cluster B personality disorders, specifically borderline personality disorder, was also considered. Bruce only meets the requirements for two of the five or more symptoms required to make the diagnosis. Bruce does experience some identity disturbance (e.g., he sometimes seems unsure of whether he is Bruce Wayne or Batman, many times moving between the two). Bruce also experiences inappropriate, intense anger or difficulty controlling anger at times when dealing with criminals. Taken together though, these two symptoms do not constitute borderline personality disorder.

When fully considered, the symptoms that Bruce Wayne is presenting with are best represented by obsessive-compulsive personality disorder. He experiences 1) an excessive devotion to work and productivity to the exclusion of leisure activities and friendships (he often disregards relaxation and social activities to pursue his mission of justice), 2) is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (Bruce refuses to deviate from his moral compass under any circumstances), 3) is reluctant to delegate tasks or to work with others unless they submit to exactly his way of doing things (this is demonstrated both in the way he mentors his sidekicks but also in the way he serves as a tactician for the Justice League), 4) shows rigidity and stubbornness (once again, Bruce does not deviate from his moral compass and refuses to abandon his war on crime even if it means he dies in the line of duty).

Treatment Recommendations
In summary, the most fitting diagnosis for Bruce Wayne (Batman) is obsessive-compulsive personality disorder. Currently, there are not any well-established treatments for obsessive-compulsive personality disorder that have been tested in large randomized clinical trials. 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 with obsessive-compulsive personality disorder include cognitive therapy, which focuses on challenging maladaptive thoughts related to the disorder. Following his experience of trauma due to an act of evil (i.e., witnessing the murder of his parents as a young boy), Bruce developed a strong moral code focused on helping others through his pursuit of justice and committed firmly to upholding it. While this has been of great benefit to the people of Gotham City and beyond, at times, it has come at the cost of his personal health and happiness. A therapeutic approach that prioritizes flexibility and healthy balance as goals may help Bruce to improve his mental health and experience less symptoms of obsessive-compulsive personality disorder.

Status at Termination
Six months later, Bruce returned to our office. He reported that a lot had happened since our first appointment. During this time, Batman faced off against Joker in what Bruce reported was the hardest battle of his life. The Joker was set to release the Endgame Virus in Gotham City. During the conflict, it appeared that both Batman and the Joker had died. Ultimately, Bruce ended up surviving, but lost all of his memories. The loss of his parents, his training, and his time as Batman, everything that made Bruce the Batman, was gone. Bruce reported that he started living a normal life, getting more involved in Wayne Enterprises, and even meeting someone to whom he got engaged. Bruce was seemingly happy and healthy. However, after some time, it all fell apart. Even without conscious access to his memory, Bruce knew he was supposed to be doing and giving more. His engagement ended and he withdrew from his more active role in Wayne Enterprises. He demanded to a heartbroken Alfred to be taken to his cave, of which he had no memory of. Even though he did not necessarily want to, he decided to be the Batman again.

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THE GORDON/SAXTON TEST

1. Was the portrayal of mental illness accurate?

The symptoms that Bruce Wayne experiences related to obsessive-compulsive personality disorder appear to be accurately depicted. Beyond that, Batman serves as an example of someone who takes what is an extremely traumatic event and uses it to find meaning and purpose in life. He uses the death of his parents as a drive to make positive changes in the world around him as both Bruce Wayne (e.g., pursuing philanthropic efforts such as an orphanage funded by the Wayne Foundation) and Batman (e.g., by keeping criminals off the street to prevent other children from experiencing what he did.

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

We find the portrayal of mental illness most broadly seen across mediums portraying Batman to be compassionate. Although authors do not typically set out to depict Batman as experiencing mental illness, it is clear that he has experienced severe trauma that influences him throughout his life. Beyond that, many of Batman’s greatest villains experience mental illness more explicitly. Particularly, in the seminal Batman: The Animated Series, these individuals are portrayed very compassionately, with Batman often empathizing with their experiences and seeking to rehabilitate them.

Overall rating: From a rating from Superman (e.g., the worst ever) to Batman (e.g., the best ever) we rate the overall depiction of Batman as… Batman (sorry Superman fans!). For the reasons above, we believe that Batman’s universe serves as an accurate and compassionate depiction of mental illness. Even as a fictional character, Batman has served as a real-life inspiration for others who are also pressed to overcome insurmountable challenges and odds (e.g., such as depicted in the documentary Legends of the Knight) or want to make a difference for those in need (e.g., organizations such as the real life Wayne Foundation).

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**Disclaimer**

Bruce Wayne, the Batman, made his debut in Detective Comics #27 on May 19, 1939. Over the last 75-plus years, Batman has been portrayed in comics, novelizations, video games, television shows, and movies by a variety of different actors, authors and directors across multiple timelines in the DC Comics Multiverse. As such, this evaluation focused on the most well-known canonical story as presented by Bruce Wayne during the timeline in the current Batman series by Scott Snyder and illustrated by Greg Capullo (which we recommend!)

 

 

Buffy’s Battle with Depression

PSYCHOLOGICAL REPORT

Name: Buffy Anne Summers (the Slayer)
Date of Birth: January 19, 1981buffy tells spike
Ethnicity/Race: descendant of the Slayer line
Education: some college, Slayer training
Date of Initial Interview: 11/7/01 (~middle of Season 6)
Date of Report: 09/24/02 (~beginning of Season 7)
Therapists: Katie Gordon, Brandon Saxton

Presenting Problem

Buffy Summers presented as a 20-year-old single woman, who was referred for treatment by her Watcher, Giles. Specifically, Giles expressed concern that Buffy did not seem like herself and that she had recently made statements that she was “going through the motions” and that she wanted “something to sing about.” Giles reportedly had faith in Buffy’s ability to cope effectively with the challenges in her life, but worried that lately he had been “standing in the way” by jumping to her rescue too frequently.

Buffy described feeling down ever since she was brought back from death through witchcraft. Consistent with this, a friend noted that Buffy “came from the grave much graver.” When she was resurrected by her friends, she was in her coffin and had to claw her way out of her own grave. This experience was incredibly traumatic for her. She also struggled with the contrast between happiness in heaven and the return to her stressful life as the Slayer, “There was no pain, no fear, no doubt, ’til they pulled me out of heaven. So that’s my refrain, I live in hell, ’cause I’ve been expelled from heaven.”

Buffy described her emotional state as, “I touch the fire, but it freezes me. I look into it, and it’s black. Why can’t I feel? My skin should crack and peel. I want the fire back.” In addition, she disclosed that she had recently become romantically involved with Spike, a vampire who was in love with her, but who she mostly disliked. She stated that her relationship with Spike was unhealthy, and that she felt disgusted with herself for being part of it.

Family History

Before being called as the Slayer at age 15, Buffy lived in Los Angeles, California with her biological mother (Joyce) and biological father (Hank). Buffy recalled that, prior to becoming the Slayer, she was “popular, superficial, and vapid…kinda like Cordelia (a former classmate of hers).” After her parents divorced when she was 16, Buffy moved to Sunnydale, California with her mother. Buffy had hoped that she would be able to leave her vampire-slaying life behind when she moved. However, she soon learned that Sunnydale was built on a Hellmouth, and that it had even higher levels of supernatural activity than Los Angeles.

Buffy reported that her father had little to no involvement in her life currently, and that she used to blame herself for that when she was younger. Buffy recalled a close relationship with her mother, who tragically and unexpectedly died from a brain aneurysm in the past year. Currently, the only family member she maintained regular, close contact with was her younger sister, Dawn. However, she reported having close friends who she viewed as family members. In addition, she viewed her Watcher, Giles, as a father figure.

buffy friends

Educational/Employment History

Throughout high school, Buffy faced numerous hardships. She often struggled to balance academics with her other responsibilities (e.g., Slayer training with Giles, nighttime patrolling to protect Sunnydale, fighting off various Big Bads). Moreover, she experienced turmoil about embracing her role as the Slayer, while still feeling a strong desire to be a “normal girl” who had time for fun with her friends and dating, a typical lifespan expectation, and was not responsible for saving the world. When asked to identify two of the most difficult events (of many) that she experienced in high school, she named 1) being killed by the Master (though her friend Xander reviving her meant a lot to her) and 2) her first love, Angel, losing his soul after she lost her virginity to him. When asked how she coped with these stressors, she stated that she was the Slayer – someone chosen to persevere and keep fighting. She also noted that her mother, her Watcher (Giles), her friends (especially Xander and Willow), and Angel (at times when he had his soul) provided support and assisted her, as much as possible, with fighting evil.

After high school graduation, Buffy began college at University of California, Sunnydale. She continued to face similar challenges related to her role as the Slayer, as well as more typical struggles of her peers (feeling used by a man who she thought was genuinely interested in her, making difficult choices about whether to continue a relationship with her boyfriend, Riley). Buffy left college due to her mother’s health problems. Without parental financial support, Buffy was in need of an income quickly and took a job in fast food at Doublemeat Palace. She ultimately tried to reapply for college, but was denied admission.

doublemeat palace

Psychiatric/Medical History

When Buffy first saw vampires in Los Angeles, she told her parents, and they scheduled a psychiatric evaluation. The mental health staff viewed her experiences as hallucinations and delusions caused by psychosis. Buffy reportedly stopped talking about vampires after a few weeks, so that she could stop the mental health services. Later, a demon causes Buffy to believe that all of her supernatural experiences and life in Sunnydale were the result of undifferentiated schizophrenia. After taking an antidote to the demon’s poison, Buffy learned that the second experience at the psychiatric hospital was actually a hallucination.

Buffy faced several severe physical injuries (including dying twice) in the past. As the Slayer, her remarkable physical resilience meant that she was not suffering from any medical problems as a result.

Diagnostic Impressions

All assessment information was obtained through record review (reading Buffy comics) and behavioral observations (i.e., binge-watching Buffy the Vampire Slayer on Netflix). The group of symptoms that Buffy presented with are best captured by a diagnosis of major depressive disorder (also referred to as depression). She exhibited five of nine depression symptoms most of the day, nearly every day for well over the minimum of a two-week period required by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The symptoms Buffy displayed were: 1) sad mood (though she tried to hide it from most of her loved ones, she broke down crying to Tara and revealed her deep, persistent sadness), 2) markedly diminished pleasure or interest in activities (as mentioned above, she reported feeling like she was “going through the motions”), 3) feelings of worthlessness or excessive guilt (when Buffy confided in Tara about her relationship with Spike, including using him to feel better about herself, she insisted that what she had done was unforgivable), 4) increased difficulty making decisions (significant indecisiveness about whether she should go back to school or get a job and whether or not she should be involved with Spike – though some of these are typical in light of her circumstances and developmental stage) or increased difficulty concentrating (she blamed herself for not noticing Willow’s magic use getting out of control or Dawn’s frequent shoplifting, and attributed this to difficulty concentrating on things outside of her own pain), and 5) thoughts of death or suicide (Buffy became invisible at one point, learned that she might die again, and then realized that she wanted to live, which implies that she did not before).

buffy crying

Treatment Recommendations

In summary, the most fitting diagnosis for Buffy Summers is major depressive disorder. Currently, there are several well-established treatments for depression that have been tested in rigorous scientific studies. These evidence-based approaches include: behavioral activation, cognitive therapy, cognitive behavioral analysis system of psychotherapy, and interpersonal therapy. In light of Buffy’s busy slaying schedule, it is also possible that she might be interested in some bibliotherapy options rather than standard treatment sessions. Two scientifically-informed options include Feeling Good: The New Mood Therapy and The Mindful Way Through Depression.

In response to numerous stressful life events (e.g., the death of her mother, her own death, having to escape her own grave, the responsibility of caring for her sister without parental support, the responsibility of saving the world), Buffy developed major depressive disorder. She attempted to hide her feelings from her loved ones and coped with her emotional pain with an unhealthy relationship with Spike. A common obstacle that arises for individuals with mental health problems is their fear that they will be judged negatively if they seek help or that they will burden friends if they speak out about it. A therapist should address these obstacles with Buffy by providing her with education about the nature of depression – including taking time to dispel myths that asking for help is a sign of weakness.

Status at Termination (beginning of Season 7)

At follow-up, Buffy returned to her baseline functioning and no longer exhibited symptoms of major depressive disorder. This change could be attributable to multiple factors. Some that likely had an impact were: 1) ending her relationship with Spike, which temporarily lifted her symptoms at times, but ultimately increased her symptoms overall, 2) having her view of herself as defective and pathetic challenged by two individuals who she trusted and who knew her very well (Tara assured her that nothing was wrong with her; Riley affirmed that she was the strongest woman he had ever known), 3) realizing that the responsibility of saving the world did not fall solely on her (her friends, Anya, Giles, and especially Xander, played a huge role in the most recent world-saving), 4) when the world did not end, she had a powerful experience of feeling glad (she previously had not felt a strong internal drive to live), and 5) her feelings of despair were replaced with an excitement and optimism about seeing her sister grow up. Each of these factors appeared to have culminated in a strong sense of purpose, a return of joy, and the reestablishing of meaningful interpersonal connections for Buffy.

buffy smile

THE GORDON/SAXTON TEST

  1. Was the portrayal of mental illness accurate?

Even in the context of a supernatural universe, Buffy’s major depressive disorder was depicted accurately. She displayed several symptoms that are described in the DSM-5 after experiencing negative life events, which commonly (but not always) precede a major depressive episode. Between the compelling (and entertaining!) acting and writing, the audience could truly get a sense of the deeply painful, often isolating, experience of depression. Moreover, the fact that Buffy – an incredibly physically and mentally strong superhero – is vulnerable to depression, may help to reduce stigma. It sends the accurate message that depression has nothing to do with weakness.

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

It is our opinion that Buffy, and her struggle with depression, were depicted with compassion. Viewers see Buffy’s attempts to feel better on her own, as well as her desire to hide her emotional pain from her loved ones in order to protect them. She was reluctant to seek help, which is understandable, but that likely prolonged her emotional pain. One of us may or may not have been brought to tears a few times by the compassion evoked through this portrayal of depression.

Overall rating: On a rating scale from Angelus (least truthful and compassionate) to Angel (most truthful and compassionate), we rate this portrayal of Buffy Summers’ depression as Angel. For the reasons described above, we believe the portrayal reflects an accurate representation of depression in a way that elicits sympathy.

Diagnosing Darth Vader

PSYCHOLOGICAL REPORT

Name: Anakin Skywalker (Darth Vader)DD
Date of Birth: 41 B.B.Y.
Age: 46 (at death)
Ethnicity/Race: Force-Sensitive Human
Education: Jedi Knight, Sith Lord
Date of Report: 03/01/16
Therapists: Katie Gordon, Ph.D., Brandon Saxton, B.S.

Presenting Problem

Anakin Skywalker (Darth Vader) presented as a widowed, 46-year-old man, who was referred for treatment by his son, Luke Skywalker. Specifically, his son expressed concern about his father’s persistent and pervasive pattern of violent, self-centered behavior, which caused significant distress and impairment to his family, co-workers, and the galaxy as a whole.

History

Anakin Skywalker was a Force-sensitive, human born on the desert planet, Tatooine. Anakin was presumed to be born of the will of the Force with no biological father. His mother, Shmi Skywalker, was enslaved when he was born. As such, Anakin was born into slavery as well. As a child, Anakin was noted for his kindness, generosity, intelligence, and willingness to risk his life for others. Even at a young age, Anakin was a very skilled pilot and mechanic.

At age nine, Anakin met Jedi Master Qui-Gon Jinn. Qui-Gon recognized Anakin as being Force-sensitive. Upon testing Anakin’s midichlorian count, it was revealed that he had a higher count than any other Jedi. Qui-Gon, who needed parts for his ship to leave the planet, bet on Anakin in an upcoming pod race. Through his skill as a pilot, Anakin won the pod race, winning not only the needed spaceship parts, but his freedom as well. Qui-Gon asked Anakin to leave the planet with him, hoping that the Jedi Council would allow him to take Anakin as a padawan learner. It was then that Qui-Gon began to suspect that Anakin might be the Chosen One, prophesized to bring balance back to the Force. With excitement, anxiety, and some regret, Anakin left his mother to train with Qui-Gon. Unfortunately, the Jedi Council ruled that Anakin was too old to begin training as a Jedi.

Qui-Gon and his padawan at the time, Obi-Wan Kenobi, were sent on a mission to protect Queen Padme Amidala. The two Jedi faced the Sith Lord, Darth Maul, and Qui-Gon was killed in the battle. With his dying breath, Qui-Gon asked Obi-Wan to take Anakin as a padawan learner despite the ruling of the Jedi Council. It was then that Anakin began his Jedi training.

Anakin’s training under Obi-Wan was not always smooth. Because he began his training at an older age, the other padawan learners were not always accepting of him. Anakin already appeared to have an emotionally labile temperament, and the stressors that he faced (e.g., being a slave, leaving his mother behind, being initially denied by the Jedi Council, losing Qui-Gon Jinn) further fueled those flames. During this period, Anakin started to become aware of how powerful his connection to the Force was. As such, he started to develop a flair of arrogance and sense of superiority over other padawan learners. Observing the power that Anakin possessed led Senator (and eventually Supreme Chancellor) Sheev Palpatine to express interest in young Anakin.

Years later, Anakin met Padme Amidala (then a senator) again, and developed intense, romantic feelings for her. His mentor, Obi-Wan, reminded and warned Anakin that those kind of feelings are expressly forbidden by the Jedi Order, as they often lead to the dark side of the Force. While Anakin was on a solo mission to protect Padme, he experienced dreams of his mother experiencing pain. Anakin believed that his dreams were a vision and quickly left with Padme to return to Tatooine. When he arrived, he found that his mother had been abducted by Tusken Raiders. Anakin found the village she was taken to, but it was too late – she died in his arms. Filled with intense rage, he slaughtered the entire village, including women and children who were not responsible for his mother’s death. He experienced immense pain and guilt at the loss of his mother and his actions. He then vowed to become powerful enough to save those he loved from death. Shortly after, he secretly married Padme.

Later on, Obi-Wan and Anakin embarked on a mission to save Palpatine from General Grevious. Despite Anakin’s reservations, Palpatine convinced him to kill Count Dooku. After the mission, Anakin learned that he was to become a father, as Padme was pregnant. They were both overjoyed by this news, but shortly after, Anakin began to have dreams about Padme dying during childbirth. Recalling how his mother died after his visions, Anakin became desperate to save Padme. He went to Master Yoda for guidance, who simply told him to let go of connections, as they lead to the dark side. Anakin was dissatisfied with Yoda’s response, which provided no comfort or solution. It was also during this period that strong distrust began to form between Palpatine, who requested Anakin to be his representative on the Jedi Council, and the Jedi Council itself, who requested Anakin to spy on Palpatine for them. Despite Anakin joining the Jedi Council to represent Palpatine, the Council still denied him the rank of Jedi Master.

Palpatine sensed the turmoil in Anakin and asked him what was troubling him. It was then that Palpatine told Anakin that he possessed the power to save an individual from death. He revealed himself to Anakin to be the Sith Lord who the Jedi Council were hunting for. He warned Anakin that if he turned him over to the Jedi Council, he would never be able to teach him to save Padme. Jedi Master Mace Windu, Anakin, and other Jedi went to arrest Palpatine. Palpatine defeated some of the Jedi, but right as Windu was about to overpower him, Anakin saved Palpatine, killing Windu. It was then that Anakin realized he had truly fallen to the dark side. Palpatine renamed him Darth Vader. Vader then lead the assault on the Jedi temple, killing all of the Jedi there, including the younglings. He then traveled to Mustafar and killed the entire Separatist Council, effectively ending the Clone Wars. Padme fled to Mustafar to try to get Vader to see the light again. When Vader saw that Obi-Wan was with her, he attacked Padme, Force-choking her. Obi-Wan attacked and dismembered Vader and left him for dead. Palpatine found Vader and rebuilt his body, resulting in him being more machine than human. Palpatine also told Vader that in his rage, he killed Padme. Vader did not know that his children survived.

Having lost his family and friends, Vader felt he had nothing left. Consequently, he became strongly loyal to the now Emperor Palpatine and embraced his new role as an enforcer for the Empire. During this period, he was described as ruthless, merciless, heartbroken, self-loathing, devoted, in emotional and physical pain, impatient, and haunted by his past. He was ruthlessly effective in his new role. About 19 years into Vader’s new role, he learned that his son, Luke, had survived. For the first time in a long time, Vader felt connection and concern for another person. This would ultimately motivate him to turn back to the light before his death.

Diagnostic Impressions

All diagnostic assessment information was gleaned through behavioral observations (i.e., watching Star Wars movies). Based on his history and presenting problems, it was hypothesized that Vader met criteria for a Cluster B personality disorder. Vader exhibited symptoms of antisocial personality disorder, borderline personality disorder, and narcissistic personality disorder. Specifically, he met five criteria for antisocial personality disorder: 1) failure to conform to social norms with respect to lawful behaviors (e.g., murders Obi-Wan Kenobi, assaults others regularly), 2) displays of irritability and aggressiveness, as indicated by repeated physical fights (e.g., using the Force to choke people), 3) reckless disregard for the safety of self or others (particularly others), and 4) lack of remorse, as indicated by being indifferent to or rationalizing having hurt or mistreated others (e.g., his justification that others, even the Jedi younglings, deserved to die). Despite these symptoms, antisocial personality disorder was ultimately ruled out due a lack of evidence of conduct disorder before age 15.

While Vader has received prior diagnoses of borderline personality disorder, the behavioral observations do not support this diagnosis. He falls short of the requirement to exhibit five or more of the nine symptoms, and only clearly meets the criteria for two symptoms: frantic efforts to avoid real or imagined abandonment (e.g., turning to the dark side in an effort to prevent Padme’s death) and intense anger and difficulty controlling anger (e.g., killing a large group of Tusken Raiders after his mother’s death, choking pregnant Padme when he thinks that she intentionally led Obi Wan Kenobi to find him in Mustafar).

The constellation of symptoms that Vader presents with appear to best be captured by a diagnosis of narcissistic personality disorder. He exhibits 1) a grandiose sense of self-importance and devalues others (e.g., regarding the Death Star, he tells Admiral Motti, “Don’t be too proud of this technological terror you’ve constructed. The power to destroy a planet is insignificant next to the power the Force,”) and 2) shows arrogant, haughty behaviors or attitudes (e.g., he tells Padme that he will be the most powerful Jedi ever), 3) a preoccupation with fantasies of unlimited success and power (e.g., he tells Padme that he will overthrow the Chancellor and, together, they will rule the galaxy and tells his son, Luke, that he can defeat the Emperor and they can rule the galaxy as father and son), 4) has a sense of entitlement  and unreasonable expectations of automatic compliance with his expectations (e.g., when Admiral Motti challenges him, Vader chokes him and says, “I find your lack of faith disturbing,” Anakin feels entitled to being named a master on the Jedi Council at a younger age than anyone else), 5) a lack of empathy/unwillingness to recognize or identify with the needs of others (e.g., refusal to see Padme and Obi-Wan’s perspectives about his choice to turn to the dark side and responding with aggression toward them), and 6) a belief that others are envious of him (e.g., tells Padme that Obi-Wan Kenobi is holding up his advancement in the Jedi Council back because of jealousy).

Treatment Recommendations

In summary, the most fitting diagnosis for Anakin Skywalker (Darth Vader) is narcissistic personality disorder. Currently, there are not any well-established treatments for narcissistic personality disorder that have been tested in large randomized clinical trials. Approaches that have been used effectively include cognitive therapy and other types of treatment focused on improving relationships with others. Due to numerous extraordinarily stressful life events (separation from his mother, the loss of his wife, being enslaved as a child, extreme physical damage to his body), Anakin developed maladaptive coping skills for dealing with his fear and anger. A therapeutic approach that prioritized building a repertoire of healthy coping skills for effectively managing emotions may have helped him to improve his mental health and reduce the harm he caused others. A common hurdle that arises for individuals with this disorder is low motivation to change in therapy. There is some hope that Anakin might have been motivated to change through his desire to connect with his children.

Status at Termination

When Vader revealed himself to Luke as his father, Luke rejected Vader and the dark side. Vader expressed sadness, not anger, over this. At a later meeting, Luke attempted to convince his father to abandon the dark side and join him, expressing that he sensed the light in his father. Vader told him that it is too late for him and turned Luke over to the Emperor. Through their interrogation of Luke, Vader learned he also had a daughter. The Emperor became angered and attacked Luke using his Force lightning capability. Unable to face this, Anakin attacked and killed the Emperor to save his son. At long last, Anakin fulfilled the destiny and returned balance to the Force. Anakin, knowing that he was dying, asked Luke to remove his helmet so he can see him with his own eyes. He told Luke that he was always right about the light in him and asked him to tell his sister as well. He then passed away peacefully, becoming one with the Force.

THE GORDON/SAXTON TEST

1. Was the portrayal of mental illness accurate?

Though it is unlikely that George Lucas purposely set out to portray Anakin as having narcissistic personality disorder, the depiction is nonetheless a fairly accurate representation of the disorder.

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

It is our opinion that Anakin was portrayed as a sympathetic character despite his numerous problematic behaviors. The films tell the story of a boy with enormous talent who faces trauma after trauma and desperately tries to cope and protect his loved ones. He is preyed upon by Palpatine during an extremely vulnerable time and is ultimately unable to resist the dark side.

Overall ratingOn a rating scale from Youngling (least accurate and least compassionate) to Jedi Master (most accurate and most compassionate), we rate this portrayal of Anakin Skywalker as Jedi Master. For the reasons described above, we believe the depiction reflects an accurate representation of narcissistic personality disorder in a way that elicits sympathy despite Anakin’s wrongdoings.