*=Video
^=Music
All Caps=Recommended
Ethan Mars is one of the main characters in the game "Heavy Rain." Ethan begins as a happily married father of two children. While shopping with his family in a crowded mall, Ethan loses track of his ten year-old son, Jason. He finally finds him, but just seconds before Jason is wandering into a street. Ethan dives into the road to save his son, but Jason is killed by an oncoming car. We next see Ethan two years later. He has been in a coma for six months and is divorced. He now avoids crowded/public areas for fear of having a panic attack. He occasionally "blacks out" and cannot remember what has happened to him during these times. One day while at the park with his remaining son Shaun, he experiences a blackout. When he regains consciousness his son is missing. Ethan and the police suspect Shaun may have been apprehended by the "Origami Killer," a serial killer who kidnaps young children and apparently drowns them in rainwater. Ethan privately receives instructions from the Origami Killer wherein he must complete a series of tasks in order to prove his love for his son. Ethan wonders if he is the Origami Killer and is testing his love for his son during his blackouts.
It should be noted that I have not interviewed Ethan in person. However, after examining many hours of data, including pseudo first-hand accounts, my diagnosis can be made with a reasonable degree of confidence.
My initial diagnostic impressions include:
-Posttraumatic Stress Disorder
-Panic Disorder With Agoraphobia
-Major Depressive Disorder, Single Episode
The following diagnoses have been frequently asserted by many people, and their validity will be examined.
-Dissociative Identity Disorder
DEPERSONALIZATION DISORDER
The essential features of Depersonalization Disorder are persistent or recurrent episodes of depersonalization characterized by a feeling of detachment or estrangement from one's self.
Diagnostic Criteria:
A: Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one's mental processes or body.
B: During the depersonalization experience, reality testing remains intact.
C: The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D: The depersonalization experience does not occur exclusively during the course of another mental disorder, such as Schizophrenia, Panic Disorder, Acute Stress Disorder, or another Dissociative Disorder, and is not due to the direct physiological effects of a substance or a general medical condition.
Analysis of Criteria
Depersonalization Disorder is a dissociative disorder wherein a person feels detached from themselves, as if they are merely an observer of themselves and not the entity in control. This is not an uncommon phenomenon to occur briefly, but the disorder is characterized by causing clinically significant distress or impairment in functioning (criteria C). Though Ethan appears to experience some sort of dissociation during his blackouts, depersonalization does not seem to accurately describe his experience. During his black outs he appears completely unaware of his surroundings (criteria B) and has no memory of these time periods. It appears another disorder may better characterize his experience (criteria D).
POSTTRAUMATIC STRESS DISORDER
The essential feature of Posttraumatic Stress Disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.
Diagnostic Criteria:
A: The person has been exposed to a traumatic event in which both of the following were present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
(2) the person's response involved intense fear, helplessness, or horror
B: The traumatic event is persistently reexperienced in one (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, and perceptions
(2) recurrent distressing dreams of the event
(3) acting or feeling as if the traumatic event were recurring
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
(5) physiological reactivity on exposure to internal or external cues that symbolize or resenble an aspect of the traumatic event
C: Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma,) as indicated by three (or more) of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect
(7) sense of a foreshortened future
D: Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigillance
(5) exaggerated startle response
E: Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
F: The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Analysis of Criteria
Ethan witnessed the death of his son, and it caused within him a reaction of fear and helplessness (criteria A). Following this traumatic event, Ethan appears to have difficulty concentrating (he frequently appears disorganized and incapable of completing routine tasks, such as caring for his son) and sleeping (criteria D1 and D3). He appears to have a strong aversion to public places (criteria B4) and experiences symptoms of Panic Attacks in crowded areas (criteria B5). Perhaps due to these aversions, Ethan avoids certain places (crowded areas) that remind him of these events (criteria C2). He seems estranged from others, including his surviving son Shaun (criteria C5). He also manifests a primarily blunted affect (criteria C6). He also seems to get much less enjoyment out of usually pleasurable activities (contrast spending time with his son before and after the trauma; criteria C4). Due to these symptoms, Ethan apparently no longer works as a successful architect and his marriage has ended in divorce (criteria F). He has apparently been experiencing all of the above for about 18 months (criteria E). It seems very clear that Ethan is suffering from Posttraumatic Stress Disorder.
Posttraumatic Stress Disorder may also be the most appropriate explanation for Ethan's blackouts. As noted in the DSM, "in rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment." This may be occurring during Ethan's blackouts. The stress of having his son Shaun kidnapped (and having heard troubling reports on the news about the Origami Killer) may also be traumatic for Ethan and he may process these overwhelming emotions while dissociated. This would explain why he had an origami figure in his hand after one blackout - his mind was processing an overwhelming trauma. Additionally, Ethan does genuinely wonder if he is a serial killer and has killed children. Such a thought would likely be far to overwhelming for his conscious mind to handle and thus he may have processed this issue while dissociated.
Posttraumatic Stress Disorder may also be the most appropriate diagnosis in describing his panic symptoms. As noted in criteria B5, a person who has experienced significant trauma may have a physiological response to stimuli associated with the trauma. In other words, Ethan may have an increased heart rate, shortness of breath, dizziness, etc. while around crowds because crowds are associated with his traumatic experience. His physiological response happens to basically resemble a cued panic attack, and he consequently avoids situations from which it might be difficult to manage a panic attack (an Agoraphobia-like response).
PANIC DISORDER WITH AGORAPHOBIA
The essential feature of Panic Disorder is the presence of recurrent, unexpected Panic Attacks followed by at least 1 month of persistent concern about having another Panic Attack, worry about the possible implication or consequences of the Panic Attacks, or a significant behavioral change related to the attacks.
Diagnostic Criteria:
A: Both (1) and (2):
(1) recurrent unexpected Panic Attacks
(2) at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:
(a) persistent concern about having additional attacks
(b) worry about the implications of the attack or its consequences (i.e. losing control, having a heart attack, "going crazy")
(c) a significant change in behavior related to the attacks
B: The presence of Agoraphobia.
C: The Panic Attacks are not due to the direct physiological effects of a substance or a general medical condition.
D: The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia, Specific Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, or Separation Anxiety Disorder.
Analysis of Criteria
Ethan does appear to have recurrent Panic Attacks (where he has a pounding heart, sweating, shaking, shortness of breath, dizziness, etc.). However, these Panic Attacks do not appear to be unexpected - that is, they appear to be connected to crowds rather than occurring randomly in a variety of settings. In other words, they are connected with a specific situation (criteria A1). Ethan appears concerned that he may have another Panic Attack (criteria A2a) and consequently avoids crowds when possible (criteria A2c).
Ethan also appears to experience some amount of Agoraphobia (anxiety about being in places or situations from which escape might be difficult in the event of a Panic Attack; criteria B).
Due to the specific nature of Ethan's Panic Attacks, he may warrant a diagnosis of Specific Phobia, Situational Type. However, the situation in question appears to be crowded areas and are likely connected to the trauma he experienced at the death of his son, Jason. As noted in the DSM, "if the Panic Attacks occur only in situations that can be associated with the traumatic event, then the Panic Attacks should be attributed to the Posttraumatic Stress Disorder." Due to the connection to Ethan's traumatic experience, his Panic Attacks may be more accurately attributed to Posttraumatic Stress Disorder (criteria D).
ADJUSTMENT DISORDER
The essential feature of Adjustment Disorder is a psychological response to an identifiable stressor or stressors that results in the development of clinically significant emotional or behavioral symptoms.
Diagnostic Criteria:
A: The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
B: These symptoms or behaviors are clinically significant as evidenced by either of the following:
(1) marked distress that is in excess of what would be expected from exposure to the stressor
(2) significant impairment in social or occupational functioning
C: The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder..
D: The symptoms do not represent bereavement.
E: Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months.
Analysis of Criteria
Ethan developed his symptoms (mentioned above) within three months of awakening from his coma following the death of his son (criteria A). His symptoms caused significant problems with his relationships to his wife and his son, and apparently his job (criteria B2). The stress related disturbance is probably better accounted for by Posttraumatic Stress Disorder (criteria C). However, in my clinical opinion, even though it is technically incorrect to diagnose both Posttraumatic Stress Disorder and Adjustment Disorder, I think it most accurately describes Ethan's experience and would be of more assistance to a clinician helping him. Ethan is not only experiencing stress from the traumatic event of his son's death, but also of the fallout of that event (i.e. divorce, job loss, split custody of his son, etc.). The enduring consequences of the stressor are characteristic of an Adjustment Disorder, and, in my opinion, most accurately describe Ethan's mental health situation. The symptoms are too extreme to be explained by bereavement (criteria D) and the consequences of the stressor are ongoing (criteria E).
MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE
The essential feature of Major Depressive Disorder is a clinical course that is characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes.
Diagnostic Criteria:
A: Presence of a single Major Depressive Episode.
B: The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Shizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
C: There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode.
Analysis of Criteria
Ethan probably meets criteria A, in that he is most likely experiencing a Major Depressive Episode for much of the game. Major Depressive Episodes are not diagnosable on their own, but they do have their own set of specific criteria which I have not duplicated here. The main reason for this is because my clinical opinion is that Ethan's depressive symptoms are more accurately explained as a result of a specific situation. Though it is appropriate to diagnose someone with Major Depressive Disorder, Adjustment Disorder, and Posttraumatic Stress Disorder, I think this is "diagnosis stacking" and only serves to muddy the clinical picture. Leaving out the diagnosis of Major Depressive Disorder may more accurately reflect the source of the depression, and thus treatment can be more focused.
SCHIZOPHRENIA
The essential features of Schizophrenia are a mixture of characteristic signs and symptoms (both positive and negative) that have been present for a significant portion of time during a 1-month period, with some signs of the disorder persisting for at least 6 months.
Diagnostic Criteria:
A: Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period:
(1) delusions*
(2) hallucinations**
(3) disorganized speech (e.g., frequent derailment or incoherence)
(4) grossly disorganized or catatonic behavior
(5) negative symptoms, i.e., affective flattening, alogia, or avolition
NOTE: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.
B: Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset.
C: Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms that meet Criterion A and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance ay be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form.
D: Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.
E: Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance or a general medical condition.
F: Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month.
*A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person's culture or subculture. When a false belief involves a value judgment, it is regarded as delusional only when the judgment is so extreme as to defy credibility. Delusional conviction occurs on a continuum and can sometimes be inferred from an individual's behavior. It is often difficult to distinguish between a delusion and an overvalued idea.
**A sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ. Hallucinations should be distinguished from illusions, in which an actual external stimulus is misperceived or misinterpreted. The person may or may not have insight into the fact that he or she is having a hallucination. One person with auditory hallucinations may recognize that he or she is having a false sensory experience, whereas another may be convinced that the source of the sensory experience has an independent physical reality. The term hallucination is not ordinarily applied to the false perceptions that occur during dreaming, while falling asleep, or when awakening. Transient hallucinatory experiences may occur in people without a mental disorder.
Analysis of Criteria
Ethan does not appear to be experiencing delusions or hallucinations (criteria A1 and A2), nor does he display disorganized speech or behavior criteria A3 and A4). He does display a blunted affect and some avolition (A5), but these are more directly attributed to depression following trauma. Since Ethan does not experience any symptoms from criteria A, an examination of the remainder of the criteria is not necessary.
DISSOCIATIVE IDENTITY DISORDER
The essential feature of Dissociative Identity Disorder is the presence of two or more distinct identities or personality states that recurrently take control of behavior.
Diagnostic Criteria:
A: The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).
B: At least two of these identities or personality states recurrently take control of the person's behavior.
C: Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
D: The disturbance is not due to the direct physiological effects of a substance or a general medical condition.
Analysis of Criteria
Ethan experiences blackouts during which he is unaware of and has no memory of what he has done during these blackouts. It appears as if he is not simply unconscious due to the fact that he has, at least on one occasion, completed tasks during his blackouts (one time when he became aware of himself following a blackout he held an origami figure in his hand, presumably of his own make). A person experiencing symptoms associated with Dissociative Identity Disorder typically have some sort of amnesia while another identity assumes control of the person's behavior, and a person may describe this dissociative experience as a blackout.
It seems unusual that no other people have witnessed Ethan during his blackouts, and thus cannot give any information about his behavior during this time. Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, consciousness, and memory. Typically when another identity is manifested in Dissociative Identity Disorder, these personalities display exaggerated parts of one's personality. For example, the primary identity will usually be passive or submissive, but another personality will be extremely aggressive and protective, while another will be extraordinarily compassionate, while another will overly intellectualize situations. Without the reports of others, it is very difficult to make a determination that this phenomenon is occurring. There is also very limited (if any) evidence to suggest that Ethan is assuming other identities during his blackouts. Accordingly, it is difficult to clinically ascertain that Ethan meets criteria A or B. Additionally, he does not meet criteria C inasmuch as he has no memory issues with regard to his personal information; that is, he knows he is Ethan Mars, that he has two children and that one died, that he is divorced, etc.
Incidentally, it is clear that the narrative of the game is designed to get the player to wonder if Ethan is experiencing Dissociative Identity Disorder. Inasmuch as it is difficult to make this determination even after knowing the full story, it appears as if this was a particularly intriguing and well thought-out story mechanic.
Final Diagnosis:
Axis I: 309.81 Posttraumatic Stress Disorder, Chronic
309.28 Adjustment Disorder, With Mixed Anxiety and Depressed Mood
300.15 Dissociative Disorder Not Otherwise Specified (Rule Out)
Axis II: V71.09 No Diagnosis on Axis II
Axis III: Deferred to medical personnel
Axis IV: Death of a family member, divorce, living alone, job loss, arrest, victim of a crime
Axis V: GAF=58
