The Psychology of Video Games Week 4: Anxiety in Games

It took 4 weeks for me to drop the ball on timely updates, but considering all that’s been going on I’m taking it as a win that it’s only a week late. On Feb 1, I started full time as a practicing psychologist. Full time clinical + part time program management with Take This, and adjunct teaching a brand new class has been a lot to handle but, like Tim Gunn, I’m gonna make it work.

Honestly, the most challenging thing about the class is finding that balance between psych and games. I talked about it more in depth in my last post, but it bears repeating that figuring out what is within scope and what is unnecessary is incredibly tricky. This was made especially clear this week with the anxiety unit.

For their homework, my students were to play or otherwise review Fractured Minds, an award-winning autobiographical-ish game by Emily Mitchell. We had some extra time in class so I figured we could play in person a bit as well. As always, I reassure my students that their feeling of comfort and safety is paramount and that if anyone needs to step out, take a walk, put in headphones, etc that I welcome them to do so. I say this so much, they probably have recurring dreams about it. I 100% believe that not only is this kind of content warning and emotion management key to ethical practice, but walks-the-walk in terms of self-care.

I just didn’t expect nearly half my class to walk out.

Image result for fractured minds game

To be clear, I’m glad they did. Ecstatic. The worst thing would be for someone to sit there, suffering. But I was truly surprised and took a long time reflecting on it. Had I missed something? Were the content warnings lacking? Is my perception of what’s “upsetting” skewed? Whatever the answer, I felt terrible and spent time talking with each student, checking in, and making sure they were ok.

In a way I’m glad it happened since this upcoming week, Week 5, is about psychosis and the game of the week is Hellblade. I’m now hyper sensitive to the boundaries my students have demonstrated and hope that I’ve made appropriate changes. The largest being that, for this upcoming class, I notified students that the second half of class – where the gameplay happens – is voluntary and that anyone who wants to go home after lecture is welcome to do so. This decision was definitely influenced by what happened with Fractured Minds, a much less intense game, but also my replay of Hellblade.

I honestly don’t remember Hellblade being so graphic, so intense. I thoroughly enjoyed my play-through but it was a different experience playing with the purpose of screening for others. Even the parts I recalled being pretty chill were still graphic, intense, or potentially upsetting. I hope some students go home and I hope some stay to play and have a deep discussion on the game, but we’ll all have to stay tuned to find out.

Anyway, this is supposed to be a post about anxiety in games… We started with the normal stuff – definition, description, and diagnoses. Although I didn’t (couldn’t) highlight every anxiety disorder, I did manage to find a character with Agoraphobia and continue to feel particularly proud of myself for that accomplishment.

The majority of the applied focus to games centered on PTSD. PTSD is pretty common in games. Some of the reasons we discussed included 1) PTSD is a “hero’s” disorder; 2) Symptoms of PTSD are easier to convert to visual representations; 3) PTSD requires a traumatic event.

Although all mental illness is stigmatized, combat PTSD is publicly viewed as one of the more “acceptable” mental illnesses (important: even so, combat PTSD is still heavily stigmatized, especially within the military). To the lay population, combat PTSD means you did something brave, served your country, etc. In a really gross way, it’s used often as like a badge of honor in storytelling. Tons of games feature combat PTSD, likely because many games are focused on combat. The wounded soldier seeking vengeance or returning home is a well-worn trope. But non-combat PTSD, PTSD related to things like surviving assault, domestic violence, or natural disasters is far rarer. Best guess? Combat PTSD = strength/bravery (coded male), non-combat PTSD = victim (coded female), regardless that both are debilitating and developing PTSD has nothing to do with any of those attributes.

Second, the symptoms of PTSD are easier to portray in a visual medium than something like depression. Flashbacks, a legitimate symptom of PTSD, are a super useful story-telling device, and other symptoms, such as hyper-vigilance, are also simple to portray through narrative or other visuals. They’re also “action-y”, used to move the story forward, share internal thoughts, and be visible to the player and NPCs.

Lastly, trauma is in the name. Post-Traumatic Stress Disorder. The use of trauma as a plot device or character development is rampant in most media and games are no exception. Notable examples include Max Payne and Deus Ex: Human Revolution which both use the death of a wife or daughter, respectively, as a substitute for a backstory and the justification of the protagonist’s action. In fact, the harming or killing of women as a catalyst for the male protagonist’s story arc is so common it even has it’s own named trope: Fridging.

Image result for she was programed with the most traumatic backstory
 “She was programmed with the most tragic backstory ever. The one day she didn’t do a perimeter check, her wedding day…..” – Wreck It Ralph (2012)

Next, we reviewed some of the current research on the use of video games as a means for treating anxiety including a study on Tetris as a way to prevent PTSD, the use of biofeedback in games like Nevermind and Mindlight, and less formal reflections on the use of casual games as anxiety management.

Next up, I loaded Fractured Minds and you already know how that went. After checking in with students and a brief break, we pushed on and played Celeste. I had students play through the very start of the game as well as the gondola scene. For those unfamiliar, about halfway through the game the main character and her friend take a gondola toward the summit of Celeste Mountain. Halfway up, the gondola breaks down and Madeline, the protagonist, experiences a panic attack. Her friend Theo names the experience as dark tendrils replace a previously peaceful scenic background. Theo says his grandfather taught him a trick to help him calm down, and what follows is an abbreviated and game-ified version of a breathing technique. The player uses the controls to keep an imagined feather within a specific frame as it floats up (inhale) and down (exhale).

Image result for celeste feather

From a clinical perspective, it’s far from perfect. For example, the pace of the feather floating up and down was a bit quicker than I’d recommend and, technically, the player is just using controls rather than actual breathing. It’s also important to realize that for some people, paying attention to their breathing can actually increase anxiety. That said, having a technique like that represented in something as public and accessible as a popular video game is exciting, encouraging, and normalizing. I wouldn’t be surprised to hear one day to hear a news story about how someone helped themselves or a friend through intense anxiety because they remembered this moment in Celeste.

During discussion where we compared portrayals in Fractured Minds to that of Celeste, it was once again brought up that the smaller, more memoir-type games seemed more intense and designed to share the visceral experience while the more abstract, more professional games were more about the concept, about providing a more generalizable experience. This does seem to speak to the differentiation between some games as personal expression, almost a therapy unto themselves, and some games as entertainment-driven but conscientious of their content. The world definitely needs both and this feels like a dissertation waiting to happen (I’ve served my time; this dissertation is on someone else).

Next week: Psychosis and Personality Disorders in Games


  • VentureBeat. (2017). Hellblade: Senua’s Sacrifice documentary. 
  • Fordham, J. & Ball, C. (2019). Framing mental health within digital games: An exploratory case study of Hellblade. JMIR Mental Health, 6(4).
  • Lindsey, P. (July 21, 2014). Gaming’s favorite villain is mental illness and this needs to stop. Polygon. Roxby, P. (Nov 24, 2017). Avatar therapy ‘reduces power of schizophrenia voices’. BBC News.
  • Avatar therapy ‘reduces power of schizophrenia voices’. BBC News.

Students were also tasked with emailing me questions in anticipation of our upcoming section on gaming controversies. I’m looking forward toward reading their questions and working that into weeks 6, 7, and 8.