Content review for this game:
Pertaining to the ESRB rating.

Blood and gore: The blood effects spurt in large droplets, puffing in clouds and in heavy amounts when you shoot an enemy. Blood does linger, splatters onto walls, floors, bodies and the screen (when enemies are shot close up); there is static blood smeared on walls and floors throughout; and you'll often see blood dripping from ceilings, balconies, etc. Bodies do linger, and (as you follow frequent trails of bloody footprints) you'll see many heavily bloodied and shredded civilian (with bloody, mashed up lower faces) and enemy bodies lying about or hanging from openings in ceilings, balconies, etc; and later on, dismembered and beheaded enemy bodies, corpses with surgical instruments sticking from their backs, as well as bloodstained and smoking skeletons, with their melted, piled flesh lying beneath them.

There is gibbing; when you shoot an enemy with the sniper rifle, shotgun (in close quarters) or throw a frag grenade, enemies will explode in clouds of large bloody chunks, as their limbs and innards (brains, entrails, etc.) lie in detail after the fact. The sniper rifle, assault rifle and Laser gun will sever enemies from the waist and dismember them from the head, legs and arms, causing heavy amounts of blood to spurt from their limbs--if Reflex mode is enabled, you'll see all in detailed slow-mo. Lastly, Hazmat soldiers have tanks on their backs, which, if shot, will cause the tanks to explode, ripping open their torsos and severing them from the waist except for their spine; if you look closely, you'll see what remains of their innards and bloodied skeleton in graphic detail. But, there is an option to turn some of the above off by going into the pause menu, selecting "Game Options," and then turning the "Full Violence" from "On" to "Off." This will disable all the real-time blood, gibbing and dismemberment for gameplay; but all the pre-existing blood on floors, walls and bodies will remain, as will most of the blood and gore in cutscenes.

In addition, a few of the enemies are grotesque and disturbing in appearance; the Abominations are former humans and failed experiments of the ATC, now mutated and crazed monsters. Garbed only in tattered green hospital scrubs, they appear painfully thin, with bones protruding from underneath their deathly pale skin; large, purple veins bulging from all over their bodies; and their heads fully wrapped in gauze, only revealing one wild, bloodshot eye, a few wiry hairs, and their gaping, bloodied and fanged mouths. The Remnants are former civilians caught in the fringes of the nuclear blast, now just shells, mutated and bloated, with heavily deformed faces and slack jaws agape. And later, unmasked Replica soldiers; because of a malfunction in their cryogenic freezing chambers, they, too, have grotesquely deformed faces.

Specific scenes of blood & gore:

(As a quick note, not only are the below scenes bloody and gory, but the majority of them are also very violent and contain many horrific and/or bizarre elements common to this genre).

The title screen's lens slowly gathers blood as it fades into the next scene.
When you and your team enter the foyer to an abandoned office building, you find a dead, bloodied body with a detailed bullet wound to the back of its head, lying face down in its own blood at what appears to be an information desk.
As you watch in a state of half consciousness with your vision blurred from the first-person view, you see as doctors with mildly bloodied frocks and masks hurriedly converse among themselves while they operate on you. Because of the pain and Alma's psychic influence, it cuts from reality to a vision from a floor perspective, as exaggerated, heavily bloodied and growling monster forms of the real doctors tear away at your torso on the operating table, causing heavy amounts of your blood to puff out and splatter onto the floor. It returns to the first-person perspective, as it abruptly shifts in and out of reality. The operator then tells you, "You'll feel a little pinch," triggering a vision of his monster form taking a huge syringe and violently stabbing it in your chest, as your blood splatters and his disturbing visage opens its mouth in a hideous howl.
After entering an open area with a set of stairs and a balcony just above you, you approach it as an orderly's bloodied body abruptly falls from it, with its blood then continuing to slowly drip down and gather onto the body and floor.
While walking down the hallway of a ruined medical facility, you hear a loud thump on your right side, prompting you to look at the glass partition. You then see what appears to be a young female nurse pressing her hand desperately against the glass, as an ATC Black-Ops soldiers comes in behind her and shoots her several times in the back, resulting in heavy blood puffing from her body, and then splattering onto the cracked window as she slides down dead.
When you turn a corner (later in the same facility) you see a crazed and heavily bloodied orderly in the distance (and from behind), as he feeds on a dead and bloodied corpse (no details seen), with its blood heavily smeared around it. You then see an ATC Black-Ops soldier approach him from behind and shoot him in the head point-blank, resulting in a moderate amount of blood splatter.
As you start to turn the corner, an ATC Black-Ops soldier is flung past you to a nearby wall by an unknown assailant, resulting in his blood splatter as he hits the wall. After turning the corner, you see a dryer at the other end of the room, with a headless and bloodied ATC's soldiers body slumped down, and its severed and bloodied head slowly rolling in the dryer. You continue to push forward and fight the enemy, as you hear their panicked screams mixed with their gunfire in the distance. While you follow the trail of bloodied bodies and approach a glass partition, you see an Abomination jump onto the glass partition, and then leap from it and off-screen onto the ATC soldier, tearing him apart--apparent from the heavy blood splatter all over the partitioned window. Further on, you see an ATC soldier being dragged in by another Abomination (with bloody results) and then later see another Abomination pull another soldier behind a counter, as it rips him apart--apparent in the cloud of blood coming from behind it.
When you approach a bloodstained and broken window overlooking the room where you were operated on, a flashback vision instigated by Alma shows, as you again see the exaggerated and bloodied monster forms tearing away (blood splatter included) at your torso on the operating table; it's revealed that Alma was psychically there keeping you in a stable condition (she wants you alive, strangely)--you then snap out of it as you encounter an Abomination.
An optional intel document mentions a crazed patient eating a man's corpse.
While running down a corridor, you hear one of your teammates mumbling in the distance. When you reach him, you find him on an operating table as his body is continuously skewered by the table's automated bladed tools, which are moving up and down in a stabbing motion, resulting in sickening squishing sounds as his blood heavily puffs from his abdomen and onto the floor. He starts to repeat in a crazed tone, "We have to help her!" (Alma), as you look into his eyes (which are glazed over red and bloodshot) and face (deathly pale, with large purple veins bulging from his face)--he then draws his last breath.
As you turn a corner, another one of your crazed teammates grabs you and pins you to a wall. Alma doesn't like this and psychically tells him to let you go; he does, and as he backs into a wall dazed and confused, Alma uses her powers to throw a temper tantrum by remotely pinning him to a wall, dragging him across the ceiling and into a large and menacing tree root that pops up from the floor. It then grabs him, drags him around the corner as you hear screams, squishing sounds and blood splatter onto the walls--after turning the corner, you see his bloodied skeleton smoking on the floor and his blood splattered about.
You see an ATC Black-Op soldier shoot a doctor (who's kneeling on his knees with his arms over his head) point-blank, causing moderate blood splatter.
As you ride a freight elevator an Abomination jumps on top of the grating and tries to get in, only to gets smooshed as the elevator presses it against the ceiling, resulting in squishing sounds, gibbing and heavy blood splatter.
You hear as another one of your crazed teammates (over the radio comms) approaches Alma, saying he can help her...you soon hear her howls and the transmission cuts out--stupid idea. He then starts to shoot at her (another bad idea), you catch up to watch from below, as he runs away from tree roots swinging at him from the windows. When you reach where he is on the second floor, Alma quickly appears and uses her power to knock you down as it pulses like a red cloud around the area. With blurred vision, you see him grabbed by the tree roots and disintegrated, which causes heavy blood splatter.
As you and your team ride in your armored vehicle to the next area, Alma induces a vision to scare you; which shows your teammates as nothing more than dead and heavily bloodied skeletons. She then unexpectedly pops out and grabs at you, causing you to snap out of the vision and back into reality.
While walking up a set of stairs in a ruined elementary school, you watch in your slow-mo Reflex mode, as two panicked ATC Black-Op soldiers run past the corridor, gradually burning up into bloodied skeletons--it's Alma's doing.
When you finally catch up to the head of the ATC's Black-Ops, he jumps you, as you're then forced to repeatedly beat him off. You continue to duke it out until you manage to force his gun under his chin and press the trigger point-blank (this sequence is actual gameplay--you are performing this yourself), causing his head to blow off and a heavy amount of blood to gush from his neck.
(This can be considered more of "Crude humor" than actual "Blood and gore.") After meeting your informant, he starts to tell you the following randomly, as he gives you the Prototype weapon: "Have you ever seen a hippo fight? They start crapping and wagging their tails really fast and sh*t just flies everywhere!"
After your informant (who's sitting in a desk chair) gives you the Prototype weapon, you watch (while facing him) as a Replica Assassin comes up behind him, grabs and lifts his head, slices it off in slow-motion with his knife (resulting in extreme detail and heavy blood splatter), drags it by the hair, and runs off with it--you later see the discarded (and detailed) head lying on a bench.
When you finally reach the amplifier (a weapon to stop Alma) and have one of your teammates strap you in, the lightly bloodied and disheveled ATC president rushes in and disables the device. Your teammate says they need the device to kill Alma. The ATC president states that she wants Alma alive for further testing, and she is going to use you (Becket) as bait to trap Alma in the chamber with you permanently. Your teammate flat out refuses to let that happen, prompting the ATC president to pull out a gun and quickly shoot her a couple times in the torso, resulting in her falling back against your viewpoint, as a moderate amount of her blood splatters onto the screen, and she then falls dead.

Intense violence: Alma has been released, and the facility holding her has been destroyed, unleashing a nuclear explosion--the previous main characters' status are unknown. You're now in the shoes of Sergeant Becket, a psychically sensitive soldier, and Alma's new target. As the nuclear explosion takes place, you're injured in the fringe blast, prompting the ATC (short for Armacham Technology Corporation) to perform an operation in order to boost your dormant abilities, and (secretly) connect you to Alma's mental wave. Because of your above-average psychic power, and new connection to Alma, she wants to absorb you; not only is she guiding you along the way, but she's also protecting you--can't be a good sign. To stop her, you'll have to navigate the environments ravaged by nuclear fallout, and fight through the ATC's Black-Ops (trying to destroy evidence), their failed experiments (now Abominations), and the psychically Replica forces, solely and unintentionally controlled by Alma's uninhibited powers, in order to reach a machine contained in a ruined facility (which boosts psychic ability) so you can try to will her away. Let's hope it works...

After living through the explosion, recovering from your surgery, and acquiring your first weapons, you're set out into the ruined environments, as you try to find out more about how to stop Alma. The base gameplay consists of using your varied arsenal to shoot through enemies as you dodge their fire, take cover behind objects and use your slow-mo Reflex mode (later on, you'll pilot an enemy mech suit to tear through waves of on-foot and mech enemies, with its mounted gattling-guns and missile launchers, and also use the mounted turret on your APC vehicle to take down more waves of enemies) to get the upper hand, as you navigate the pitch-black environments with your flashlight and their deliberately barricaded paths, by taking constant detours with the many stairs, doors, elevators, and vents. You'll also solve some mild puzzles by disabling locks and electric/gas hazards blocking your way with switches and valves, all the while collecting medkits, ammo, weapons, and Reflex boosters, in order to survive the enemy's constant onslaughts and Alma's frequent hauntings.

Enemies, at first, are made up of the ATC's Black-Ops, and later on, Abominations (failed and crazed, once human experiments of the ATC's), Specters (hostile and ghostly projections of the city's former residence), Remnants (surviving human bodies of the city, who are now grotesque and mutated monsters, controlling corpses like puppet masters) and Alma's psychically controlled Replica soldiers (with her pure mental rage driving them). You'll be fighting them with a pistol, automatic and combat shotgun, assault rifle, submachine gun, sniper rifle, missile launcher, grenades (frag, incendiary, shock and proximity), the Napalm Cannon (spurts balls of flame), the Hammerhead (shoots large metal bolts), the Laser gun (shoots a continuous and unending laser beam), and the Prototype (shoots blue energy orbs).

The combat system is chaotic and intensely violent, with you tearing through enemies with your varied arsenal, as you see bullets rip through their bodies in your slow-mo, heightened Reflex mode, while the dozens of shots kick up clouds of dust and debris, as bullet casings clink to the floor; the Hammerhead to shoot large metal bolts, which fully impale and violently pin enemies and their limbs to nearby walls; the Napalm cannon and incendiary grenades, to scorch environments and set enemies ablaze; frag grenades, proximity mines, close-by explosive objects and tanks strapped to certain enemies back to take out anyone nearby (causing bodies, dust and debris to fly); shock grenades and nearby electrical boxes to shock, and then shoot them while they're stunned; the Prototype weapon to incinerate enemies down to the skeleton; and the butt of your weapons to beat them down in close quarters.

When shot, the ATC Black-Ops and Replica soldiers will, at first, fall from gunfire, get back up, limp slowly to cover when injured, and after they're finally downed, they'll scream (Power Armor mechs spark/explode, Replica Assassins discharge electricity) and fly back, as their final relex actions make them fire off shots and fall in contorted positions; and when set on fire, they'll try to roll and pat themselves out (sometimes surprisingly succeeding, but most often not) before flailing about and then dying. Add this, the overwhelming odds (dozens of enemies against just you); environments' destructible nature (glass shatters; random objects spark, explode and fly off shelves; bullets break away at and imbed themselves in walls; explosions crumble nearby pillars, leaving their underwire exposed, etc.) and their disheveled appearance (once public buildings are messily overturned, their doors barricaded by random furniture and boarded up, their walls newly ridden by bullets, etc.), it gives combat a jarring, tense and hostile feel--familiar settings, unfamiliar occupants.

After breaking through doors, piling out of elevators and rappeling from sunroofs and/or helicopters, enemies will hurriedly converse with each other to flank and rush you, as they do, attacking with the same weapons, including sniper rifles (which kill in a couple of hits) and missile launchers (killing in one hit) from afar, while those closer will kick and slide over objects to make cover, as they pop out and put heavy fire on your position, toss grenades your way and bash you with the butt of their weapons. The more powerful ATC Pyro soldiers (taking many more hits to kill than common enemies) will attack with Napalm cannons, as they burn you alive and scorch the area; huge Power Armor mechs (protected by their energy-shields, taking dozens of more hits to destroy than other enemies) will attack with their mounted gattling-guns and bash with their arms up close; and the later Replica Assassins use their stealth camo to disappear and reappear, as they jump quickly from wall to wall, then rush and slice at you in close quarters--enemies don't mess around.

You'll later roam the city devastated by nuclear fallout; now figures of ash, former citizens are frozen in the positions they were before death, and the city is overturned, with its streets torn away, vehicles scattered and crushed, buildings in ruin and flame, smoking into the ravaged, sunless sky--the destruction is insurmountable. This fallout has created horrific enemies (like aforementioned Specters--phantom-like apparitions that flicker in and out of visibilty, springing in soul form from their dead bodies--and Remnants--grotesque shells of former humans, controlling nearby dead bodies with psychically projected puppet strings visible at their extremeties), and freed others; Abominations are lightning fast and agile, and when encountered, they'll come in groups while crawling on all fours, skittering across the floor and abruptly jumping from ceilings to walls, as they rush and often latch onto you with their claws, all the while you have to beat them off as you stare into their disturbing faces...

The majority of gameplay sequences are also tense and quite suspenseful, as you'll often have to dodge large, falling objects; escape a secret facility before it explodes, scuttle a tram before it crashes; or evacuate elevators before they fall--even the environments are against you. On top of this, you'll frequently find yourself sabotaged or ambushed by the enemy; as you navigate through a Replica factory surrounded by their cryogenic chambers, they'll exit them all around (you don't know where they'll come from next); and later on, the head of the ATC Black-Ops traps you in a faulty training course, and then uses a bound and controlled Abomination to psychically command Replica soldiers to attack--you're always on the offense.

When not fighting the enemy, you'll have to deal with Alma's hauntings; as you walk through the many ruined, dark and abandoned corridors, random objects violently shake and fly off shelves; lights flicker and blow out; doors slam as you approach and are then deliberately barricaded. And as you get nearer to Alma's immense psychic presence, the screen will go into slow-mo and start to pulse, reddening around the edges as colors fade and you hear your labored breath. Strange static sounds abruptly cut on/off on your radio, all the while tense and eerie music plays, and Alma (adult, nude and haggard) finally appears unexpectedly from a distance before disappearing into ashes, or abruptly grabbing onto you as you try to beat her off. To make matters worse, your team is psychically sensitive, and Alma uses this to split you up and pick them off one by one--since you're almost always alone, it gives a great sense of fear, isolation and foreboding; Alma is everywhere and she's still in control.

The cutscenes contain a few chaotic explosions; the majority of your teammates are injured or killed; Alma continues to show you creepy psychic visions and flashbacks throughout; and it's reiterated how Alma was imprisoned at only 7 years-old by her own father, experimented on, and then artificially inpregnated at only 15, then 16, to create the next generation of pyschically enhanced soldiers. Concerning age group, it's definitely not for younger teens; there may be an option to turn off blood and gore in combat, but even with it disabled, it leaves tons of blood splattered and smeared in the environments (not to mention the dozens of bloodied bodies); it's packed with language (including over three dozen uses of the f-word); the story is tragic, bizarre and twisted; as this is a horror game, the nature of your encounters with Alma and most enemies are horrific; and Alma forces sex (albeit brief and abstract) on your character at the end--this is plainly more suited to older teens and adults.

Specific scenes of Intense violence:

(As a quick note, not only are the below scenes violent, but the many of them contain horrific, tense and/or bizarre elements common to this genre).

You see from first-person as you get up from the pavement hands first. When you look up, Alma's child form appears, a disheveled teddy bear hanging loosely at her side. As you follow her, you see the sky is filled with ash and red storm clouds, and the city in complete ruin, with cars overturned and buildings ripped apart in flame. She then disappears down a sinkhole in the road, you follow, and immediately find yourself sitting in your team's APC (or armored vehicle). You hear strange music coming from a music box sitting to your right, you look over at it, and when you look back up, Alma's face abruptly flashes before you point-blank (with appropriate sound effects and tense music), morphing back into one of your teammates, which snaps you back into reality--it was all a vision.
While you navigate an early area, you walk into a wading pool, triggering a vision in which you find yourself submerged in a deep, dark pool, Alma lying haggard, nude and motionless up ahead, tied with many tubes to the chamber's systems (this was her former cell). She then abruptly swims up and into your face (again with tense sound effects and music), as you snap out of it.
As you approach a morgue, you see Alma flashing from body to body, and then disappearing. When you reach the middle of the room, she abruptly slides them all out from their containers at the same time (tense, creepy music included).
After entering a burning room, you see an ATC Pyro solider set an orderly on fire, causing him to flail about and scream as he burns alive (no detail seen).
Several intel documents in the ruined elementary school detail experiments the ATC was doing on the children, like drugging their cafeteria food, etc.
As you approach the school principal's office window, the former principal, now a Remnant, abruptly presses it's grotesque face against the window (with the appropriate sounds and music), howls loudly, breaks it open and runs away.
A letter to the principal in one of the intel documents has a concerned mother asking about her two kids, who both say they're having nightmares of being locked in dark places, poked with needles and shown violent images.

Sexual themes: Near the very beginning, while you and a teammate approach a tall, ritzy-looking building, he remarks, "The only penthouse I ever seen had staples in the middle!" And the last level's title (which contains the second scene, below), appropriately (if not crudely) describes the game's ending: "Climax."

As you walk through a hall, you encounter Alma, who then psychically pins you to the corner of the ceiling. She slowly walks toward you staring, and seeing your disgust at her current form, she switches to her more attractive form (for the first time), and then vanishes--her way of showing sexual advances.
After you finally reach, strap into and (try to) activate the psychic amplifier, the screen abruptly goes red and into slow-mo, as your vision blurs and Alma approaches your chair slowly from the left side (you see the side of her false form's breast and behind--the rest is covered by her long hair). It flashes to her true and corpse-like form (for contrast), as she slowly reaches and leans toward your face, with her two forms flashing intermittently. You then find yourself in the reoccurring vision's setting, with the rolling hills and the large tree (its sky blazing red, with clouds of abrasive dust violently blowing about), as you try to reactivate the amplifier. However, you find your last teammate's fading, but still active spirit, who (as you are trying to pull the switch) comes up and grabs you (his appearance is that of a burned and decomposed face), prompting a brief, first-person view of Alma (in her more appealing form; more detail in "Partial nudity) writhing on your lap and moaning (no lower views or details seen). You continue to try and activate the figurative console as it switches positions, while you fight through apparitions of your teammate, while it switches between his attacks and more brief views of Alma writhing up/down and moaning on your lap. When you finally press the switch, it causes Alma to moan a bit more intensely, having what appears to be her brief "climax." You soon wake up and view from first-person, as she reveals herself from a distance, and then slowly walks toward you, fully pregnant, guiding your hand to her stomach.

Partial Nudity: Alma appears nude throughout (in both the gameplay and cutscenes), and you will frequently see her from the front, sides and behind, in quick flashes as she phases in and out of visibility, or when she gets close and violently grabs onto you during her hauntings. However, her appearance is that of an emaciated corpse; she has pale and blotchy skin, with her skeleton visibly poking out from underneath; long, black matted hair that covers the majority of her breast and behind; and you never actually see any detailed views of her lower area, as the camera doesn't focus on that region specifically--her true form is not in the least bit appealing.

And although, later on, she does start to infrequently take on the form of a full-bodied and living young woman (for Becket's sake), which is admittedly more attractive, only the fullness and normalcy of her skin are affected--everything else (including her demented nature, and matted hair covering the rest of her body) stays the same. And because of the very abstract and brief nature of the encounter, the shaking screen, your blurred and bloodshot vision, and the large red, pulsing clouds induced by her immense psychic power, it removes your ability to ever see any details.

Strong language: There are (including the optional intel text messages) over three dozen uses of the f-word and sh*t, over a dozen uses of d*mn and hell, under a dozen uses of God d*mn, a**, b*tch and SoB, three uses of bastard and p*ss, and one use of p*ssy, blow (as in "Blow me!"), God and "Pooch" screw. Other than the main script, enemies will infrequently use d*mn, sh*t, SoB and the f-word while you fight, and during their overheard converations. There is no option to turn language off.