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).
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
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).
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.
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).
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).
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.
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).
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February 19, 2023
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