The Therapist Gamer

Issac is the main character in "The Binding of Isaac."  His age is unknown, but he appears very young.  Isaac's mother, perhaps influenced by watching religious broadcasts but almost certainly due to psychosis, believes she hears the voice of God.  She obeys the voice, which tells her Isaac needs to be saved from his sin.  In accordance with this, she removes all of his possessions and strips him of his clothes.  She later locks him in a room by himself. She is then told by the voice that she needs to sacrifice Isaac to prove her devotion to God.  She grabs a butcher knife and approaches Isaac's room.  Isaac sees her approach through a crack in his door.  He looks around his room in a panic, looking for a place to hide.  He finds a trap door to the basement under a rug, and jumps down.  The gameplay takes place entirely in the basement, where Isaac battles monsters and gathers items which increase and expand his abilities.  His primary offensive maneuver is to shoot his ever-flowing tears.  The first ending of the game (there are several) implies that Isaac never really left his room, and it is probable the entire game is played out in Isaac's mind.

 

It should be noted that I have not visited with Isaac in person.  However, after examining available data my diagnosis can be made with a reasonable degree of confidence.  

 

My initial diagnostic impressions include:

-Reactive Attachment Disorder of Infancy or Early Childhood

 

 

 

 

REACTIVE ATTACHMENT DISORDER OF INFANCY OR EARLY CHILDHOOD

The essential feature of Reactive Attachment Disorder is markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before age 5 years and is associated with grossly pathological care.

 

Diagnostic Criteria:

 

A:  Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either (1) or (2):

     (1) persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifested by excessively inhibited, hypervigilant or highly        ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen        watchfulness)

     (2) diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative                strangers or lack of selectivity in choice of attachment figures)

 

B:  The disturbance is Criterion A is not accounted for solely by developmental delay (as in Mental Retardation) and does not meet criteria for a Pervasive Developmental Disorder.

 

C:  Pathogenic care as evidenced by at least one of the following:

     (1) persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection

     (2) persistent disregard of the child's basic physical needs

     (3) repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care)

 

D: There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbance in Criterion A began following the pathogenic care in Criteria C).

 

Analysis of Criteria

The behavior of Isaac's mother would be characterized as pathogenic care (criteria C).  She took his belongings and clothing and locked him in a room for an undisclosed amount of time (criteria C1 and C2).  She invoked intense fear as she approached him with a deadly weapon with the intent to kill him.  The assumption in this diagnosis is that this pathogenic care has caused significant attachment issues with Isaac.  

 

The diagnosis requires a significant impact on Isaac's social relatedness, and available data regarding this aspect of his functioning is limited.  Due to the content of Isaac's experience in the basement, it appears as if he would like to avoid all people and things with which he comes into contact.  He tries to defeat monsters by keeping his distance and shooting his tears.  This behavior most closely aligns with criteria A1.  

 

Isaac does not appear to have any issues with his IQ (as in Mental Retardation, now called an Intellectual Disability); he is shown functioning normally prior to his mothers psychosis (criteria B).  Without expounding upon all criteria for each Pervasive Developmental Disorder, it again appears he was functioning normally prior to the above described incidents, thus such a diagnosis seems inappropriate.

 

Without additional information, it is unclear if Isaac meets criteria for Reactive Attachment Disorder.  However, given the nature of his relationship to his caregiver, it is my opinion that he would likely manifest symptoms of this disorder in the future, especially if there is not an immediate change in his caregiver.

 

 

 

 

Additional Thoughts

Unlike most video game characters, Isaac is very young.  Due to his age, virtually all diagnoses are inappropriate explanations for his behavior and inner experience.  One reason for this is that there is still significant time for Isaac to adapt to his environment.  Another is that certain thought processes are not unusual for children who are very young, such as vivid daydreaming.  However, due to the serious nature of Isaac's treatment, Isaac may develop particularly disabling mental health issues is he does not receive help.

 

It is interesting to note that Isaac is actually within the room throughout the entire game.  That is, he is not actually in a basement fighting monsters, but this experience is happening in his own mind.  Whether this is a hallucinatory experience or a dissociative one is unknown.  The content of Isaac's role-playing is revealing; he essentially wanders around attempting to strengthen himself so that he can ultimately kill his mother.  This firmly displays the tension he feels in his relationship with his primary caregiver.  Such a relationship can lead to a myriad of issues later in life if Isaac does not soon find a safe environment where he can both explore his trauma in his own way and can live without fear.

 

Some of the possible endings in the game imply that Isaac may be experiencing dissociative states.  For example, there are a variety of characters that the player can choose to be the protagonist, but it appears that these are all separate identities of Isaac.  If Isaac does not receive effective treatment and live in a more stable environment, it is possible Isaac may develop symptoms of Dissociative Identity Disorder.  This disorder is thought to originate as a result of extreme trauma where a person's psyche (or "ego," or "sense of self") simply cannot remain conscious of it's experience because it is too overwhelming.  A person unconsciously develops different identities for the different aspects of themselves; for example, a person's primary identity might be timid, but another is very protective and aggressive, and another is extremely emotional, while yet another acts like a young child.  This symptomatology is very rare but is essentially a defense mechanism originating in extreme situations.  A person as young as Isaac still has ample time to integrate any fractures in his identity, but, if left untreated, his mental health could significantly deteriorate.

 

Mental health professions understand a great deal about Schizophrenia, but it is still unknown why exactly some people develop symptoms.  There are likely a wide variety of genetic and environmental factors.  One environmental factor thought to contribute to symptoms of Schizophrenia is the interaction between parents and children.  It can be difficult for children to make sense of the world, and having a mother be both loving and try to kill you sends a very confusing message.  It can be difficult for a child to feel a sense of stability in this type of environment.  When reality is too difficult to cope with or understand, theoretically the mind might come up with it's own reality in order to survive.  This might be manifest in the positive ("in addition to what is typical") symptoms of Schizophrenia, namely delusions and hallucinations.

 

Unfortunately, child abuse and neglect is not uncommon.  However, children can be surprisingly resilient.  It is possible that Isaac will not develop any problematic symptoms at all.  This is especially true if there is an immediate change in his environment and he can again experience stability in his life, including from his primary caregivers.  Ideally he would have contact with multiple people from whom he feels love and unconditional acceptance, as all children should.

 

 

 

 

Final Diagnosis:

 

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Axis I: 313.89 Reactive Attachment Disorder of Infancy or Early Childhood, Inhibited Type (Rule Out)

Axis II: V71.09 No Diagnosis on Axis II

Axis III: Deferred to medical personnel

Axis IV: Child Abuse, Child Neglect, Parent-Child Relational Problem

Axis V: GAF=12