Bloodborne is a 2015 horror-action RPG directed by Hidetaka Miyazaki (Demon's Soul and Dark Souls), developed by From Software (Japan) and published exclusively on PS4. The game music has received broad critical acclaim for its singular, intense Gothic horror sound performed by large orchestra, choir, soloists, percussion and utilizing extended orchestral techniques. This lecture will examine the musical style and orchestral approaches in the score. We will discuss the dissonant harmony, the horror-inspired melodic gestures, the "wall of sound" approaches and the blood-curdling action music. We will show how the challenging choral writing and the extended orchestral techniques evoked the desperate, disease-plagued City of Yharnam. We will also discuss how the orchestration helped unify the "sound" and aesthetics while working with a multi-cultural creative team (three Japanese staff composers at From Software, and three US guest composers). Additionally, the lecture will examine the communication and logistical challenges inherent with teams based across three continents, and strategies to promote successful musical productions.