Abnormal Psychology Case Report

I had to write a case report about a fictional character for my Abnormal Psychology class. In the case report, I had to diagnose said character with a mental disorder. I chose to diagnose Josh from the game Until Dawn. Until Dawn is a 2015 horror choice game, it's one of my favorite video games ever. This report will contain some spoilers for the game. I'm really proud of the paper, so I uploaded it here. Below is the file that I turned in for the assignment. I recommend looking at that, but I'll copy and paste the paper below.

Case Report - EllaFredericks (1).pdf

Download PDF • 9.49MB

Joshua (or Josh) Washington is a character from the 2015 horror video game Until Dawn. He is described as persistent, creative, and playful (thoughtful, loving, and complex in the original game). He is studying psychology in college. He hates being bossed around. He loves his family. Josh is the son of Melina and Bob Washington, the latter is a Hollywood horror movie director. Josh would like to follow in his fathers footsteps career wise. His favorite quote is “It takes no imagination to live within your means” by Francis Ford Coppola, who is an American filmmaker (The Godfather). Josh has 2 younger sisters that are twins: Hannah and Beth Washington. He’s pretty close with his sisters and protective of them. Josh is part of a friend group consisting of his sisters, him, his best friend since elementary school Chris, and other friends (aged 18-19): Sam, Mike, Emily, Matt, Ashely, and Jessica 

In the beginning of the game, the group is up in the mountains at the Washington family lodge. His family must be well off in order to own this vacation lodge. We see Hannah run out of the lodge after being incredibly embarrassed in a prank from her friends. Her sister, Beth, runs after her. Josh is passed out drunk while this is occuring (Chris too). The audience knows that the two sisters fall off a cliff and die, but everyone else just knows that they never came back that night and are now missing. Josh is 19 years old when his 16 year old sisters go missing. Following their death, he drops out of college. In the rest of the game, which is set a year after this incident (2015), he is 20 years old. Sam was a close friend with Hannah and tries to be there for Josh after their passing.

The year following his sisters’ disappearance, Josh invites his friends back to Blackwood mountain for a reunion. The group starts experiencing some crazy events on the mountain. Some think the house is haunted because they see a ghost and other weird things. Others think there is a murderer with them since one character has to pick between a saw killing his crush (Ashley) or his best friend (Josh). Regardless, the saw will go for Josh and ‘kill’ him. After escaping this, Chris and Ashley will be captured again and knocked out. They wake up strapped to chairs and Chris is told to choose between killing himself with a gun or killing Ashley. If he doesn't choose, a saw will kill them both. Turns out the gun is fake and these weird things have all been orchestrated by Josh himself. He used special effects, a fake dummy, and pig guts to fake his own death (which is why picking the crush does not change the outcome of where the saw goes). Josh orchestrates this “psycho” persona, who gives the character the decision of who to kill, and the hauntings to scare his friends. He wanted to get back at them for pulling the prank that drove his sisters to their supposed death. 

When Josh reveals himself to be the psycho, his friends are in hysterics and very upset with him. They thought he was dead. They thought there was a psycho on the mountain with them. They feel incredibly betrayed by their friend who just gave them a lifetime of trauma. Josh doesn't seem to understand the extent of what he did. He laughs while they all say his name in surprise. He says “Oh, oh very good. Every one of you! Got my name! And after all you’ve been through! Good-good-good-good. I mean how does it feel? Right? How does it feel? Do you enjoy being terrorized? Humiliated, I mean, panicked? All those emotions that my sisters got to feel once one year ago! Only guess what! They didn’t get to laugh it off! No! Nope! No no no! They’re gone.” One of the other characters, Mike, then says “I don’t know if you noticed this, Josh, but no one of us are laughing.” Josh responds, “Oh come, come-come-come-come. Why the long faces? Come on! It’s good to get the heart racing every now and then, right?” After this conversation, Mike and Chris take Josh outside to be tied up since they think he is crazy. 

There are two important pieces of evidence you can find in the game that may explain Josh's actions. One being his cell phone open to a text conversation between him and his therapist, Dr Hill. Dr Hill asks Josh “Are you still taking your meds?”, after reading an email josh had sent about his plan to terrorize his friends. The second piece of evidence is Josh's psychiatric history, including: physician history, history of prescribed antidepressants, and summary of treatment. 

screenshots from the game

The evidence shows that Josh was referred at the age of 9 after an incident at school and started taking Fluoxetine (an SSRI). He went through 2 other types of antidepressants before arriving at his current one: Phenezoline. This was prescribed by Dr.Hill for Josh's “strong symptoms of Major Depressive Disorder”. Josh had been referred to Dr.Hill “03/14/2014 due to potential suicide risk”. He was hospitalized for 30 days until the doctor had decided he was stable on this medication.

 A doctor's note warns that upon withdrawal the patient could have hallucinations, paranoia, aggressiveness, and slurred speech (among others). It is clear to the audience that Josh is suffering from these symptoms in particular. While his actions could be chalked up to going through withdrawals since he stopped taking his medication; I believe that taking a larger look at the situation reveals there is more than meets the eye. 

There are other symptoms, Josh exhibits, that make me look at other disorders, such as Schizophrenia. There’s also the fact that none of his antidepressants have seemed to work indefinitely. Schizophrenia is a “psychotic disorder in which personal, social, and occupational functioning deteriorates as a result of unusual perceptions, odd thoughts, disturbed emotions, and motor irregularities.” The first part of the DSM Diagnoses says that “For 1+ months, a person displays 2+ of the following symptoms much of the time: Delusions, Hallucinations, Disorganized Speech, Unusual motor activity, including catatonia, and negative symptoms.” The hardest part about diagnosing Josh is knowing how long he has exhibited certain symptoms. The game only gives us so much information. It’s unclear whether it’s been a month, but Josh definitely displays delusions and hallucinations. This also meets the second diagnostic criteria that says “At least 1 of the symptoms MUST be delusions, hallucinations, or disorganized speech.” There are times that Josh displays a bit of disorganized speech as well. 

The 3rd diagnostic criteria says “Person functions much more poorly in various life spheres than was the case prior to the symptoms.” I believe this to be true. He’s had a rough go and is not taking it well. A healthy person would not not do what he did. It’s clear that his symptoms are having a large impact on him. The final diagnostic criteria says “(Beyond this 1+month of intense symptoms), the person continues to display some degree of impaired functioning for at least 5 more months.” Once again, it’s unclear. Josh has had some kind of symptoms since age 9 to be referred to doctors and medication, but we can’t be sure what symptoms. 

Since the timing is unclear, I would also consider Brief Psychotic Disorder (symptoms for less than a month) or Schizophreniform Disorder (symptoms for 1-6 months). Taking into account, his previous (but possibly incorrect) diagnosis of Major Depressive Disorder, Schizoaffective Disorder could also be considered. It is “marked symptoms of both schizophrenia and a major depressive episode or a manic episode (6 months or more).” I also thought about bipolar 1, with the possibility that this is a manic episode, but decided against it after looking at all the symptoms. 

Josh has delusions of Grandiose. He has cameras set up everywhere to film his ‘prank’ on his friends. He plans to upload the video and believes that they will all become famous because of it.

It should also be noted that in between chapters of the game, we as the player go to therapy sessions. Right before Josh is revealed as the psycho, we learn that the therapist is talking to the psycho. After the reveal, we realize that this therapist is Dr. Hill. All of these sessions have been in Josh’s head. As the game goes on, the setting of these sessions becomes more and more decrepit as Josh spirals further and further. 

Evidence of disorganized speech can already be seen in the way Josh responds to his friends' reactions to his prank. Another example of disorganized speech occurs when Chris and Mike are tying Josh up. The conversation is as follows:

Josh: Right right right still. Can't tie em up if they just wiggle around. Leave me a little wiggle room, huh? Ow! Not so tight, okay? Not so tight, okay! I can’t wiggle around. Plastic ties. That’s where it’s at. Yeah.

Mike: What… in god’s name is he talking about?

Josh: Plastic ties, plastic ties. Way more effective for hostage type scenarios. 

Chris: This is hard to watch….

Mike: He ever say this kind of shit before?

Josh: Guaranteed for at least three hostages, or your money back!

Chris: No, I have never seen him like this…

Josh: huh huh huh (laughs) Everybody is stupid, stupid, stupid, stupid…

Chris and Ash, Chirs is an ass, Ashley’s a dumb dumb (laughs)

Chris: I'm sorry what did you say?

Josh: Well I said your a dummy, dummy (laughs)

Chris: What is wrong with you

Josh: Ohh Ashely ‘I never imagined in my wildest dreams that you liked me…!’

Chirs: Stop

Josh: (kissing noises) You know what that sound is? It’s the sound of you never kissing Ashely, you pussy.

—----------

Josh: Hey Mike. Mike, Mike, Mike, Mike, Mike. Mike!

Mike: What?

Josh: What happened with Jess, Mike?

Mike: You know what happened.

Josh: No… No… I don’t… I got a problem, Mike.. I don't remember killing Jess..

Mike: Christ..

Josh: I mean, like, I feel like I would remember killing her, you know? 

Throughout this conversation we see multiple instances of formal thought disorders which are “disturbances in the production and organization of thought”. When he rapidly switches from topics (ties to his friends being stupid to Ashely and Chris) this shows ‘Loose Associations’. He also makes a lot of repeated statements or words, such as “plastic ties” and “stupid”. This pattern of speech is called ‘Perseveration’. He uses rhyme when he says “Leave it to the pros, bros” but I think this is the only case. Use of rhymes to express oneself is called ‘Clang’. 

 This example and the previous one both show disorganized speech and inappropriate affect, which is another feature of schizophrenia. Inappropriate Affect is the “display of emotions unsuited to the current situation.” After the reveal, he laughs instead of realizing how upset his friends are. This is inappropriate during this occasion. When he is tied up he jokes about killing Jess which is very inappropriate since the others truly believe her to be dead and think he was involved because of his prank (he was not, it’s a supernatural plot line that ‘killed’ Jess).

After Josh has been tied up and left alone, the group discovers that there are Supernatural forces at work on the mountain. They go back to get him only to find out he is gone. The next time we see Josh, he's deep in the mines suffering from vivid auditory and visual hallucinations. We know that these are hallucinations and not supernatural elements, because Mike later finds Josh and doesn't see any of what Josh is seeing while Josh is seeing it. He sees his dead sisters, Dr.Hill, and a giant pig head. His sisters ask “Why didn't you save us Josh?” Dr. Hill says things such as “Spoiled little brat”,“You are a coward”, and “You manipulate”. We see that Josh has severe guilt over the death of his sisters (since he was asleep when they ran out). Dr. Hill also says “Do you even believe that I am real?”, “Ah…the heart of the problem. It all comes down to this: can you really tell the difference anymore?” This shows how deep Josh is into his psychosis.

He knows that this prank was wrong, but chose to go through with it anyway. I believe this also shows some social withdrawal, which is another element of Schizophrenia. Dr. Hill as a hallucination says, “You had so many people who cared about you, who were willing to help but at every turn you chose to push them away… And now you're all alone.” This quote is probably the most revealing piece of his social withdrawal. 

One course of treatment could be looking at antipsychotic medications. The antidepressants have not been working. Since Josh has mostly positive symptoms (hallucinations, delusions, disorganized speech), he has type 1 Schizophrenia. Antipsychotic medications are known to improve positive symptoms more than negative symptoms. He could take a 2nd generation drug, which are at least as effective in treating symptoms as 1st generation drugs and have fewer extrapyramidal symptoms, such as Clozapine. 

Since Josh has gone off his medication before, it would be advised to combine this with some kind of therapy. He might also need to be hospitalized if thoughts of suicide come back. The CBT treatment Hallucination reinterpretation and acceptance may help Josh. It could help him challenge the ideas that his sister's death is his fault, he’s spoiled and ungrateful, ect. However, his psychiatric report says CBT has not been approved effectively in the past. I wonder if this might change with the new medication. Family therapy may help as well since Josh’s parents also lost his sisters, which is the trigger to creating his plan and dropping out of school. Hopefully this would help, since Josh is close with his family. Although, I worry his dad would be busy with his job.