I've read through the 48 page PDF. The premise is intense. It gives me Hunter the Reckoning vibes with a healthy heaping of the Wyrm, Pentex, and Banes/Fomori from White Wolf publishing's old/classic World of Darkness.
The game has a big narrative focus. Mechanics are simple, draw cards. High card wins. The only way to get an edge in opposed challenges is to put a relationship you have with an NPC in danger, or put them in literal danger. I like how you work that in narratively. I can see that risk to relationships is a big part of the game. There is no way to undo that damage to a NPC. That is big. How fast are you trying to have characters self destruct? Do you intend for Before the Worms to be a short or long form game? I would also want some way for my character’s own abilities to play a role in addition to the drama that, optionally, can come into play by drawing on a relationship with an NPC. Otherwise there is no difference between between backgrounds and skillsets.
There is a structured gameplay loop, and you did a good job outlining it in a simple, straight forward manner. The Breathe step is a good idea. A pause period, for an emotionally intense game, where you can think about your next steps and decompress a bit at the same time. There is some solid guidance and a play example that are informaive without dragging on,
The tight gameplay loop, coupled with the light and quick to learn system may make it good for solo play. I might try a solo session out. If I do, I'll let you know how it goes.
While reading I noticed a couple things you may want to edit:
About the dying light of your your (game description)
The person may dead ( pg. 31)