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).

play too much

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.”

no controlvideo gamesjh

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!

psych101

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.

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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.