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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