Last week we discussed some common psychiatric problems that affect thought. This week, we'll look more closely at anxiety and depression, and how to use them in your games.

In modern gaming, the majority of GMs and players have a strong awareness of mood. However for the most part the emphasis is on external story mood rather than the depiction of internal moods.

We don't often see story protagonists that are depressed or anxious, and when we do it's often couched in melodrama or humour rather than aiming for realism.

It's fair to argue that most if us don't turn up to roleplaying sessions to feel depressed or anxious.

For many of us gaming is escapism, with the desire to get away from the troubles of life. Despite this, there are times when it can serve a narrative to depict depression, and when it can even be cathartic to roleplay out sadness accurately.

Depression

Depression is depressingly common.

About one in three of us will consult to see our doctors for depression at some time during our lifetimes. Pretty much all of us have felt low or depressed at one stage or another. If your game setting aims for realism then depression should turn up sooner or later.

Depression can be part of a lifetime pattern of low mood, or it can be a reaction to a single event (for example, a bereavement). In role-playing games heroes and adventurers tend to be quite proactive people, not really taken to dark moods of melancholy (unless you're playing Vampire, or are into emo/goth roleplaying). This means that depression is typically something you'll want to role-play in response to an event.

For GMs, accurately depicting a depressed non-player character may help to establish the overall mood of a game, or can simply add colour and realism to your game worlds.

Psychiatrists and doctors have grown to recognize sets of symptoms that are often seen in depression.

Low Mood

I see that you're thinking, dear reader...: "Aesclupius, you're a genius. Depressed people have low mood, who'd have thought it?"

Clearly my years of medical school were not wasted.

Low mood classically manifests as sadness and tearfulness, along with feelings of low self-esteem, guilt and worthlessness. A depressed person may be apathetic, and be suffering from anhedonia, which means that they find they are not able to feel positive emotions.

For example, an errant knight who has sunk into melancholy because of a fair maiden has spurned him may find that the joust no longer gives him pleasure, and that while his comrades are joking and laughing around him he feels only sadness.

Loss of concentration is also common, and occasionally paranoia and depersonalisation (a sense that you are not yourself) can set in.

A cunning GM could work in feelings of depersonalisation into a game setting where (thanks to magic, spirits, holograms or whatever) things are sometimes actually not real. A player character could be growing more paranoid, worrying that someone is manipulating his mind when actually it is merely his own low mood that is loosening his grip on reality.

Somatic symptoms

A depressed person has no appetite, cannot sleep at night, and often loses libido. Over time weight loss and constipation will often occur. Women may get amenorrhoea (cessation of monthly periods), and men erectile dysfunction. In some cultures, it is common for depressed people to present to their doctors with abdominal or chest pains, as the low mood manifests with very real and physical symptoms.

Suicide and Self Harm

Statistically, young women are the group most likely to attempt suicide, and elderly men are the group most likely to succeed at suicide. Self harming behaviour is commonplace in depression, and in game settings with magic and demons this needn't be limited to self-cutting. Imagine, for example, a spirit shaman who seeks to self-harm might carve runes into his skin to bind pain spirits into himself.

Why people self-harm or attempt suicide varies. For some, it can be a cry for help and the only way of getting attention from an uncaring world. For others, it can be because the pain of self-harming drowns out the sadness and psychological pain for a while. For others still it can be a sincere wish to die and to end all troubles. For many though, the reasons aren't clear or rational, as it is difficult to be rational when you are feeling depressed.

Mania

Bipolar affective disorder, more commonly called Manic-Depression is a condition of periodic mood swings that affects about 1% of the population.

Features of mania include euphoria, hyperactivity, delusions and hallucinations. A typical feature is "flight of ideas", where a manic individual will leap from one idea to the next, with often completely unconnected thoughts flowing one after another.

Mania probably has less role in an average story than depression, so we won't dwell on it too long in this article.

Anxiety

Anxiety and depression go hand-in-hand and have many shared symptoms. Like depression, anxiety can be part of a lifelong mood disorder, or reactive to certain events.

RPGs being what they are, few players are likely to want to play anxious types, preferring square-jawed stoics. Characters prone to anxiety make excellent NPCs on the other hand, if only to provide contrast to the stalwart heroes. Of course, for certain genres and gaming groups a player character panic may be a great role-playing challenge and thematically appropriate. For example, in a Call of Cthulhu game it's perfectly appropriate for even the most seasoned investigator to break down when faced with gibbering horrors.

Panic Attacks

A panic attack is defined as "a discrete paroxysm of severe anxiety which is associated with unpleasant symptoms of autonomic arousal".

Like so many medical definitions this description is both painstakingly accurate and painfully dull.

True panic attacks occur without obvious precipitant, but even in real life psychiatry this is a grey area. A person prone to panic attacks might panic as a result of going into a crowded room, or just from thinking about a crowded room. In RPGs, heroes or NPCs might panic in any adrenaline-rush situation, be it being hunted by an alien on a starship, or barricaded in against hordes of brain-hungry zombies.

Typically the panic attack starts with a rising feeling of anxiety, and tingling sensations in fingers and toes. Breathing gets faster, and the chest feels tight. Trembling sets in, and the heart starts to thump in the chest. As these symptoms begin the panicker is frightened even more and starts to breath faster and faster, often hyperventilating and wheezing. Faintness and nausea soon follow, and often the panicker is convinced that he is going to die, or is having a heart attack. Often derealisation sets in, as everything becomes dreamlike and unreal.

Mood Stories

Hopefully this article has given you some ideas. Most of this is likely intuitive to you already – we've all felt anxious and sad at times in our life. On the other hand, ask yourself when you last used depression or anxiety as a story or role-playing tool, and whether doing so might add to your gaming sessions.

More Medical Musings next month, till then, happy (or sad, if you prefer) gaming!