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Introduction
Jeremy Reed is an 18-year-old Caucasian
male who was referred to counseling by his academic advisor for
depression. He says that adjusting to
university life has been difficult, and he has been feeling increasingly
depressed. He began playing World of
Warcraft on his computer to relieve stress and cope with his depressed
feelings. He became so involved in the
game that he began neglecting his homework, and his grades are suffering. His academic advisor referred him to
counseling so he does not lose his full-ride scholarship to the
university.
The client says that playing World of Warcraft makes him “feel good,” and he does not want to stop. He has made new friends and become a “top player.” He admits to feeling more depressed and irritable when he is not playing the game. I explain to Jeremy—who is a biology major—that he feels good when he plays World of Warcraft because the activity activates the reward system in his brain and stimulates the release of dopamine. The more he activates this system, however, the more he craves the gratifying pleasure produced by the game. He needs to spend more hours playing the game to reach that same level of pleasure and craves playing the game when he is not able to do so. Playing the game has become more important to him than his academic performance, so he is neglecting his schoolwork and falling behind. As he loses control over his impulse to play, I explain, his life will spiral more and more out of control. He is at great risk for not sleeping and eating, neglecting his hygiene, alienating his roommate, and losing his scholarship and admission to the university if he does not reduce his game playing and start improving his academic performance. Jeremy agrees that this is true but also states that he does not want to completely give up playing the game (Gros et al., 2020, pp. 2-4; Tavormina & Tavormina, 2017, pp. 422-424).
Clinical
Assessment
For this assessment, I am
using the Therapist Clinical Assessment/Psychosocial Assessment tools used
routinely at Flagstaff Medical Center Behavioral Health Unit in Flagstaff,
Arizona, and the PHQ-9 questionnaire because I am familiar with these forms. The PHQ-9 is used to screen clients for
symptoms of depression and has a proven track record of accuracy and
reliability. Clients who fill out the
form are scored based on their responses.
Scores equal to or greater than 10 can indicate a depressive disorder (American
Psychological Association, 2020, para. 1-2).
The client, Jeremy Reed, presents as
withdrawn with a flat affect and a disheveled appearance. His thought processes are linear and logical
with organized thinking. He is alert and
oriented. His speech is coherent and
clear, but he is delayed in his responses.
His psychomotor activity appears normal, but he makes poor eye
contact. His thought content is
realistic, but he exhibits poor insight into his excessive video game activity
even though his memory and judgment are within normal limits. He denies hearing voices, having
hallucinations, or experiencing extreme mood swings.
Jeremy denies any current suicidal and
homicidal ideation. He denies any actual
self-harm or harm to others. He denies
any thoughts of suicide/homicide in the past or making any gestures or threats
of violence against others.
The client denies any history of sexual, verbal, emotional, or physical abuse. He does not recall witnessing any extreme acts of violence. He reports that his parents argue sometimes but always resolve their differences amicably. He is an only child and has no half-siblings or step-siblings.
Jeremy confirms that he is a healthy
heterosexual male with little sexual experience. He is currently single and not sexually
active. Although he would like to have a
girlfriend, he believes it would interfere even more with his studies.
The client says he is a nominal
Protestant and only attends church at Christmas and Easter. He has experimented with yoga and meditation
in the past to live a healthier lifestyle.
He does not routinely pray or engage in spiritual practices.
Jeremy currently lives on campus in a
dorm and has no housing needs. He is
unemployed at the moment but worked part-time at Burger King in high
school. He is studying biology and plans
a career as a biologist. Since he has a
full-ride scholarship to the university, his parents help out with his
expenses. He says he does not want to
lose his scholarship or disappoint his parents.
The client has no military experience
and no legal difficulties. He has never
been arrested or suspended from school. As far as he knows, his developmental
history was normal.
Jeremy says he played basketball in high school and still enjoys playing when he can find the time and other players. He has no significant medical history, no known allergies, and takes no prescribed medications. The client appears well-nourished and physically fit. His tonsils were removed at age 10. He broke his arm when he fell off his bike at age 12. He is already registered with the university’s student health services. Currently, he reports staying up late playing video games, feeling tired the next day, and eating too much junk food. He says he lacks the motivation and concentration to study.
The client denies any mental health
history. He states that his depression
and anxiety began a couple of months ago when he began his freshman year of
college. This is his first time living
away from home, and he is having trouble adjusting to university life, living
with a roommate, and being away from his family. He is carrying a full load of credits and
feels stressed out and overwhelmed by all the homework, expectations, and
pressure.
Jeremy believes his paternal grandfather
was a heavy smoker and alcohol drinker.
His father drinks alcohol occasionally, mostly on holidays. His mother takes Vistaril occasionally for
anxiety. He admits to trying cannabis
twice but did not like it. He denies all
other substance use except alcohol, which he uses occasionally on the
weekends. His only source of caffeine is
Coca-Cola.
The client states that his main form of
recreation right now is playing Internet video games, i.e., World of
Warcraft. He wants to cut back and
resume his studying, but he derives a lot of satisfaction from the game and
does not want to stop playing the game completely. He admits that he loses track of time while
on the game. He is not fully motivated
to quit.
Jeremy describes his strengths as being goal-oriented and a good student. He is strongly motivated to complete his college degree and start work as a biologist. He describes his weaknesses as being too introverted and serious. He believes he has poor coping skills when it comes to stress. He wants help overcoming his depression and anxiety but says he is not interested in taking medication. Although he does not see playing video games as a serious problem, he admits that it has already affected his grades and academic standing. His PHQ-9 score is 13, with 4 boxes checked in the gray areas. His score indicates moderate depression that is making it difficult for him to function at his normal baseline (American Psychological Association, 2020, para. 1-3).
Probable
Diagnoses and Treatment Plan
Probable
Diagnoses
Problem
#1 – Adjustment Disorder with Mixed Anxiety and Depressed Mood (ICD Code F43.23) ( ICD-10 Coded, 2022, para. 1)
Adjustment disorder
occurs when a person is faced with a stressful life situation, such as going
away to school. Jeremy describes having
a difficult time adjusting to university life and
being
away from home. He has no prior history
of depression, anxiety, or other mental health issues. His symptoms appeared less than three months
ago after arriving on campus for his freshman year, meeting the DSM-V
criteria. He reports increasing
depression and anxiety that are affecting his ability to cope with his new
situation. If Jeremy agrees with the
assessment and treatment plan, his prognosis looks good. (American Psychiatric
Association, 2015, pp. 120-121; Kenardy, 2014, para. 1-3; Mayo Clinic, 2023,
para. 1-13).
Problem
#2 – Internet Gaming Disorder (no ICD code until ICD-11) ( Petry et al., 2015,
pp. 1,7)
Internet gaming disorder (IGD) appears in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V) in Section III under the heading of “Conditions for Further Study.” The DSM-V provides criteria for IGD that closely align with the criteria for other addictive disorders, like substance use disorder and gambling disorder. Clients who meet at least five of the criteria could be considered suffering from or at high risk for Internet gaming disorder (Petry et al., 2015, pp. 1-5).
Jeremy has been playing Internet video
games to relieve stress, anxiety, and depression. He has been spending increasing amounts of
time playing video games and spending less time sleeping and studying. As a result, his academic performance has
declined, and he risks losing his full-ride scholarship. Currently, Jeremy meets six of the criteria
on the DSM-V list of criteria: preoccupation, tolerance, neglecting other
activities, escapism, and risking losing his
educational
opportunities. He has only been playing
for a couple of months and is not fully motivated to quit, even though he
recognizes that he needs to make some changes in his life. If
he
agrees with the assessment and treatment plan, however, his prognosis looks
good (Petry et al., 2015, pp. 2-3).
Treatment
Plan
Goals
and Objective
Jeremy’s primary concern is protecting
his full-ride scholarship and earning his biology degree. His second goal is to learn new coping skills
to deal with his depression, anxiety, and stress. His third goal is to achieve more balance in
his life between studying and recreation.
His fourth goal is to reduce his time playing video games and
participate in more physical activities, like basketball. Overall, the client’s objective is to return
to his normal baseline status before going away to college. He wants the same self-confidence and control
over his life that he had before. He
wants to regain his motivation and commitment to studying and succeeding in
school. He wants a positive outcome that
will help him grow as a person and mature into adulthood.
Action Plan
Psychotherapy is the primary
evidence-based treatment for both adjustment disorder and Internet gaming
disorder (IGD). The client will benefit
from weekly psychotherapy sessions to discuss how and why leaving home and
starting college has made such a huge impact on his well-being, including his
use of video games to relieve stress. If
psychotherapy is insufficient to stabilize the client, a course of medication
may be helpful. The client, however, is
unwilling to try medication at this time (American
Psychiatric Association, 2015, pp. 63, 121; Gros et al.,
2020, p. 15; Kenardy, 2014, para.
4, 6-7, 10; Mayo Clinic, 2023, para. 22-23; Petry et al., 2015, p. 6; Tavormina
& Tavormina, 2017, p. 424; Torres-Rodriguez et al., 2017, pp. 1003,
1005-1006, 1010-1011).
Interventions
Cognitive behavioral therapy (CBT) is effective in helping clients to recognize and re-frame harmful patterns of thought and behavior. The client will be referred to a therapist who is proficient in CBT since it has been proven successful in treating both adjustment disorder and IGD. I will encourage the client to continue seeing me on a weekly basis at the clinic for one-to-one motivational and support counseling and provide him with opportunities to participate in clinical workshops that will help him to learn new skills in stress management, anger management, relaxation activities, mindfulness and resilience training, and goal-focused solutions. With Jeremy’s cooperation, we will devise a schedule that maps out times for study, recreation, and playing video games that supports his class schedule and enhances his goals and objective. I will suggest that he join a campus support group for new students. I will refer him to mental health peer support services for monitoring and help. If the client requires medication, I will refer him to a psychiatrist or psychiatric nurse practitioner for evaluation and prescriptions.
I
will get consent from the client to speak to his parents, make them aware of
the situation, and offer them support.
Since Jeremy is in a vulnerable age group, he needs intense support to
get through this temporary setback.
Otherwise, this could turn into an ongoing issue (American Psychiatric
Association, 2015, pp. 63, 121; Gros et al., 2020, p. 15; Kenardy, 2014, para.
4, 6-7, 10; Mayo Clinic, 2023, para. 22-23; Petry et al., 2015, p. 6; Tavormina
& Tavormina, 2017, p. 424; Torres-Rodriguez et al., 2017, pp. 1003,
1005-1006, 1010-1011).
Challenges
Since Jeremy is highly motivated to
protect his full-ride scholarship and complete his degree, his prognosis is
good as long as he follows the treatment plan.
Challenges include ongoing depression, anxiety, and stress that may
undermine his motivation, time constraints due to carrying a full load, and
relapsing on playing video games. I will
provide him with literature and books that will help him to understand the
biological, neurological, and psychological nature of his problems. This may pique his interest as a biology
student and keep him involved in his
therapy. I will suggest that he drop any extra credits
that he is taking. The client will be
given positive encouragement and reinforcement to stick to his goals. I will work with his assigned peer support person to monitor his progress
and participation.
Conclusion
Eighteen-year-old Jeremy Reed was referred to my office for depression, anxiety, and excessive playing of video games by his academic advisor. Jeremy’s symptoms began when he moved into the campus dorm to start his freshman year of college a few months ago. Since then, he has been spending more time playing video games and less time studying. His academic performance has suffered, putting his full-ride scholarship at risk.
This client is positive for symptoms of
adjustment disorder and Internet gaming disorder. His age makes him a high risk for long-term
mental health issues, including suicide, if he does not participate in
treatment. If he cannot control, reduce,
or eliminate his video game activity, he will continue to decline academically,
which will impact other areas of his life (Kenardy, 2014, para. 2).
American
Psychiatric Association. (2015). Understanding mental disorders: Your guide
to
dsm-5. Washington: American
Psychiatric Publishing.
American
Psychological Association. (2020). Patient health questionnaire. American
psychological association.
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http://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/
patient-health.
Gros,
L., Debue, N., Lete, J., van de Leemput, C. (2020). Video game addiction and
emotional
states: Possible confusion between
pleasure and happiness. Frontiers in psychology.
doi: 10.3389/fpsyg.2019.02894.
ICD-10
Coded. (2022). ICD-10-cm code f43.23. ICD-10 coded. Retrieved from
http://www.icd10coded.com/cm/F43.23/
Kenardy,
J. (2014). Treatment guidance for common mental health disorders: Adjustment
disorder. Australian psychological society
inpsych 2014, 36(5). Retrieved from
http://www.psychology.org.au/inpsych/2014/october/kenardy.
Mayo
Staff Writers. (2023). Adjustment disorders. Mayo clinic. Retrieved from
http://www.mayoclinic.org/diseases-conditions/adjustment-disorders/diagnosis-treatment/
drc-20355230.
Petry,
N.M., Rehbein, F., Ko, C., O’Brien, C.P. (2015). Internet gaming disorder in
the dsm-5.
Current psychiatry reports, 17(72).
doi: 10.1007/s11920-015-0610-0.
Tavormina,
M.G.M., Tavormina, R. (2017). Playing with video games: Going to a new
addiction. Psychiatria danubina, 29(3), 422-426.
Torres-Rodriguez,
A., Griffiths, M.D., Carbonell, X. (2017). The treatment of internet gaming
disorder: A brief overview of the
pipatic program. International journal of mental health
addiction. doi:
10.1007/s11469-017-9825-0.
February 19, 2023
Copyright 2023 Dawn Pisturino. All Rights Reserved.
