Mental disorders

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The GM should choose how characters in the campaign world think and therefore talk about insanity before play begins. In many fantasy games, the term “insane” serves as an all-encompassing term that represents everything an inhabitant knows or understands about the full spectrum of mental disorders. In others, different forms of insanity may be identified for what they are.

Mental Disorders

This section offers descriptions of many specific mental disorders. Where appropriate, suggested modifiers to characters’ attack rolls, saves, and checks are also given.

Anxiety Disorders

Even a seasoned adventurer feels anxious before braving a dragon’s cave, and the farmers in the village might worry that their crops will not survive until harvest. These fears are a normal, natural part of living in a danger-filled environment such as a d20 campaign setting, but in some cases these anxieties overwhelm an individual, causing inactivity, distress, and even severe behavioral problems. When fear and anxiety overwhelm a character for a prolonged period of time, the character suffers from an anxiety disorder. The most common forms of anxiety disorders are described below.

Generalized Anxiety Disorder

The character suffers from a variety of physical and emotional symptoms that can be grouped into certain categories.

Motor Tension: Jitteriness, aches, twitches, restlessness, easily startled, easily fatigued, and so on. All attack rolls, Fortitude and Reflex saves, and all checks involving Strength, Dexterity, or Constitution take a -2 penalty.

Autonomic Hyperactivity: Sweating, racing heart, dizziness, clammy hands, flushed or pallid face, rapid pulse and respiration even when at rest, and so on. All attack rolls, saves, and checks take a -2 penalty.

Expectations of Doom: Anxieties, worries, fears, and especially anticipations of misfortune. All attack rolls, saves, and checks take a -2 morale penalty.

Vigilance: Distraction, inability to focus, insomnia, irritability, impatience. All Will saves and checks involving Intelligence, Wisdom, or Charisma take a -4 morale penalty.

Panic Disorder (Panic Attack): This illness is marked by a discrete period of fear in which symptoms develop rapidly. Within minutes palpitation, sweating, trembling, and difficulty in breathing develop, strong enough that the victim fears immediate death or insanity. Burdened with the recurrence of these episodes, she fears their return. This reaction often leads to agoraphobia (see below).

Agoraphobia (Fear of Open Places): The character becomes very nervous outside familiar surroundings and must make a DC 15 Will save in order to leave home or engage socially. May be linked to panic disorder (see above) or to a related phobia (see below), such as uranophobia (fear of the sky), baraphobia (fear of loss of gravity), or xenophobia (fear of strangers).

Obsessive-Compulsive Disorder: This illness manifests in one of two main forms, obsessive thoughts or compulsive actions; some characters exhibit both.

Obsessions: The character cannot help thinking about an idea, image, or impulse incessantly, often involving violence and self-doubt. These ideas are frequently repugnant to the character, but they are so strong that during times of stress she may be unable to concentrate on anything else, even if doing so is necessary for her survival. Obsessive impulses can be very dangerous when combined with auditory hallucinations, since the “voices” may urge the character to take some dangerous or hostile course of action.

Compulsions: The character insists on performing ritual actions, such as touching a doorway at left, right, and top before passing through it. Though she may agree that the actions are senseless, the need to perform them is overpowering and may last for 1d10 rounds. Even in times of great stress, the character may ignore her survival in order to perform the actions.

Post-Traumatic Stress Disorder

After a traumatic event, perhaps even years later, the character begins to relive the trauma through persistent thoughts, dreams, and flashbacks. Correspondingly, the character loses interest in daily activities. She may return to normal once the memories have been thoroughly explored and understood, but that process may take years.

Phobia or Mania

A character afflicted by a phobia or a mania persistently fears a particular object or situation. She realizes that the fear is excessive and irrational, but the fear is disturbing enough that she avoids the stimulus.

Phobia: A DC 15 Will check is required for a character to be able to force herself into (or remain within) the presence of the object of her phobia, and even then the character takes a -2 morale penalty as long as the object of fear remains. In severe cases, the object of the phobia is imagined to be omnipresent, perhaps hidden—thus, someone with severe acrophobia (fear of heights) might be frightened when in an enclosed room on the upper story of a building, even if there were no window or other way to see how high up the room was. As many phobias exist as one cares to notice or name.

Mania: Manias are rarer than phobias. A character affected by a mania is inordinately fond of a particular stimulus and takes great pains to be with it or near it. When the character’s sexuality is involved, the mania may be termed a fetish. Thus, teratophobia would be an inordinate fear of monsters, while teratophilia would be an unhealthy (possibly sexual) attraction to them. See the lists of phobias for ideas on what sorts of disorders could manifest as manias.

Dissociative Disorders

Individuals suffering from dissociative disorders cannot maintain a complete awareness of themselves, their surroundings, or time. The disorder often involves some great previous trauma that is too terrible to remember. Characters who have gone insane from an encounter with powerful monsters often suffer from some form of dissociative disorder.

Dissociative Amnesia (Psychogenic Amnesia): This is the inability to recall important personal information, brought on by a desire to avoid unpleasant memories. The character must make a DC 20 Will save to recall such details or the cause of the amnesia. Since the horror of evil creatures and disturbing truths is the probable cause of this amnesia, as an optional rule the GM may choose to reset the character’s Knowledge (forbidden lore) modifier to +0 and her maximum Sanity to 99 while this disorder holds sway: The horror returns only when the character’s memories do.

Dissociative Fugue: The character flees from home or work and cannot recall her past. Once the flight halts, the character may assume an entirely new identity.

Dissociative Identity Disorder (Multiple Personality Disorder): The character appears to harbor more than one personality, each of which is dominant at times and has its own distinct behavior, name, and even gender. The player needs to keep track of the character’s different personalities. (Each one has the same ability scores and game statistics, but different goals, outlooks, and attitudes.)

Eating Disorders

These disorders can be incredibly debilitating and even lead to starvation. They are conditions that may continue for many years, sometimes continually endangering the patient.

Anorexia Nervosa: The character has an overpowering fear of becoming fat and consequently loses weight, as well as taking Constitution damage (at a rate of 1d8 points per week). Even when she is no more than skin and bones, the character continues to see herself as overweight. Without intervention, she may literally starve herself to death.

Bulimia Nervosa: The character frequently eats large amounts of food during secret binges. An eating episode may continue until abdominal distress or self-induced vomiting occurs. Feelings of depression and guilt frequently follow such episodes.

Impulse Control Disorders

These disorders include compulsive gambling, pathological lying, kleptomania (compulsive stealing), and pyromania (the compulsion to set fires).

Intermittent Explosive Disorder: The character is recognizably impulsive and aggressive, and at times gives way to uncontrollable rages that result in assault or destruction of property.

Mood Disorders

These disorders affect the victim’s attitude and outlook. Mild mood disorders can be almost impossible to detect without prolonged contact with an individual, but severe disorders usually have noticeable symptoms.

Depression: Symptoms of this illness include changes in appetite, weight gain or loss, too much or too little sleep, persistent feeling of tiredness or sluggishness, and feelings of worthlessness or guilt, leading in severe cases to hallucinations, delusions, stupor, or thoughts of suicide. All attack rolls, saves, and checks take a -4 morale penalty. A predisposition to use alcohol or other mood-altering substances in an attempt at self-medication exists. A character suffering from severe chronic depression may give up virtually all effort from feelings of hopelessness—for example, deciding not to get out of bed for two years.

Mania: The character has a fairly constant euphoric or possibly irritable mood. Symptoms include a general increase in activity, talkativeness, increased self-esteem to the point of delusion, decreased need for sleep, being easily distracted, willingness for dangerous or imprudent activities such as reckless driving, delusions, hallucinations, and bizarre behavior. All attack rolls, saves, and checks take a -4 morale penalty A predisposition to use alcohol or other substances in an attempt at self-medication exists.

Bipolar Mood Disorder: The character oscillates between mood states, sometimes staying in one mood for weeks at a time, sometimes rapidly switching from one to another. Also known as manic depressive.

Personality Disorders

These long-term disorders have almost constant effects on a character’s behavior, making it difficult for him to interact with others and often making him unpleasant to be around as well. This is an important point to keep in mind when roleplaying—few players want to spend time with another player character suffering from a personality disorder.

In game terms, the character takes a -4 penalty on all Charisma-based checks. In addition, the attitudes of NPCs the character encounters are shifted in a negative direction. When determining NPC atitudes, the player must make a Charisma check for the character. On a successful check, the attitude of the NPC in question shifts one step toward hostile; on a failed check, the attitude of the NPC in question shifts two steps toward hostile.

Personality disorders are classified in the following categories.

Antisocial: Short-sighted and reckless behavior, habitual liar, confrontational, fails to meet obligations (job, bills, relationships), disregards rights and feelings of others.

Avoidant: Oversensitive to rejection, low self-esteem, socially withdrawn.

Borderline: Rapid mood shifts, impulsive, unable to control temper, chronic boredom.

Compulsive: Perfectionist, authoritarian, indecisive from fear of making mistakes, difficulty expressing emotions.

Dependent: Lacks self-confidence; seeks another to look up to, follow, and subordinate herself to (“codependent”).

Histrionic: Overly dramatic, craves attention and excitement, overreacts, displays temper tantrums, may threaten suicide if thwarted.

Narcissistic: Exaggerated sense of self-importance, craves attention and admiration, considers others’ rights and feelings as of lesser importance.

Passive-Aggressive: Procrastinator, stubborn, intentionally forgetful, deliberately inefficient. Sabotages own performance on a regular basis.

Paranoid: Jealous, easily offended, suspicious, humorless, secretive, vigilant; exaggerates magnitude of offenses against oneself, refuses to accept blame.

Schizoid: Emotionally cold, aloof, has few friends; indifferent to praise or criticism.

GMs should realize that, while these traits may work for an interesting NPC from whom the players must extract information or a favor, their antisocial nature makes them ill-suited for members of an adventuring party.

Psychosexual Disorders

Recognizable disorders of this type include transsexualism (a belief that one is actually a member of the opposite sex), impaired sexual desire or function, nymphomania and satyriasis (inordinate and uncontrollable sexual appetite in women and men, respectively), and paraphilia (requirement of an abnormal sexual stimulus, such as sadism, masochism, necrophilia, pedophilia, exhibitionism, voyeurism, fetishism, or bestiality).

Most of these disorders could make players of the afflicted characters uncomfortable and thus are not appropriate for most roleplaying groups, although they can make for striking (if unpleasant) NPCs.

Psychospecies Disorders

These disorders are specific to fantasy environments and involve the victim of one believing that she is a different type of creature. A victim might believe that she is a construct (and therefore immune to critical hits) or any other creature type that she has encountered. When a victim has a psychospecies disorder associated with a creature that has specific weaknesses (for example, a human thinking he'’s a vampire), then the victim’s behavior changes become more noticeable (such as a fear of holy symbols and sunlight).

Schizophrenia and Other Psychotic Disorders

A psychotic character experiences a break with reality. Symptoms can include delusions, hallucinations, and cognitive impairment. In general, only alchemical substances or magic can treat these kinds of disorders. Note, however, that many psychotic characters suffer from the delusion that nothing is wrong with them, and hence they feel no need to take their medication.

Schizophrenia (Schizophreniform Disorder, Dementia Praecox)

A schizophrenic character’s attention span and ability to concentration are greatly diminished; to reflect this, use only one-half of the character’s normal skill modifier on any skill check requiring attentiveness (such as Disable Device, Spot, Search, Open Lock, and of course Concentration). Symptoms include bizarre delusions, paranoia, auditory hallucinations (“hearing voices”), incoherent speech, emotional detachment, social withdrawal, bizarre behavior, and a lack of the sense of self.

A schizophrenic character may fit into one of the following categories.

Undifferentiated: Impaired cognitive function, emotional detachment.

Disorganized: Inappropriate behavior, shallow emotional responses, delusions, hallucinations.

Catatonic: Mutism (loss of ability to talk), extreme compliance, absence of all voluntary movements, complete immobility (“statuism”).

Paranoid: Delusions of persecution, illogical thinking, hallucinations.

Symptoms from more than one type can occur in the same individual, along with mood disorders (see above). For example, catatonic schizophrenics sometimes have manic episodes of extreme activity alternating with periods of complete withdrawal. Schizophrenia brought on by sudden stress is called acute schizophrenia; characters who go insane and babble of vast global conspiracies usually are diagnosed as suffering from “acute paranoid schizophrenia.”

Other Psychotic Disorders

By some definitions, all severe mental illnesses are classified as psychoses, including mood disorders, dementia, and anxiety disorders. This section deals with some of the interesting behavioral syndromes that may turn up in your game.

Amok: “Running amok,” an outburst of violence and aggressive or homicidal behavior directed at people and property. Amnesia, return to consciousness, and exhaustion occur following the episode. During a killing spree, the character utilizes whatever weapons are on hand.

Boufee Detirant: Sudden outburst of aggressive, agitated behavior and marked confusion, sometimes accompanied by visual and auditory hallucinations or paranoia.

Brain Fag: Impaired concentration and feelings of fatigue, pains in the neck and head, a sense that worms are crawling inside one’s head.

Ghost Sickness: Weakness, loss of appetite, feelings of suffocation, nightmares, and a pervasive feeling of terror, attributed as a sending from witches or malign otherworldly powers.

Piblokto: “Arctic madness,” wherein the afflicted rips off clothing and runs howling like an animal through the snow.

Susto: A variety of somatic and psychological symptoms attributed to a traumatic incident so frightening that it dislodged the victim’s spirit from her body.

Taijin Kyofusho: “Face-to-face” phobia, an intense anxiety when in the presence of other people; fearfulness that one’s appearance, odor, or behavior is offensive.

Voodoo Death: Belief that a hex or curse can bring about misfortune, disability, and death through some spiritual mechanism. Often the victim self-fulfills the hexer’s prophecy by refusing to eat and drink, resulting in dehydration and starvation.

Wacinko: Anger, withdrawal, mutism, and immobility, leading to illness and suicide.

Wendigo Syndrome: The afflicted believes she is a personification of the Wendigo, a cannibalistic creature with an icy heart.

Shared Paranoid Disorder (Shared Delusional Disorder, Folie a Deux)

The character takes on the delusional system of another paranoid individual from being in close contact with that person.

Sleep Disorders

These disorders include insomnia (character has difficulty falling asleep or staying asleep) and narcolepsy (character frequently falls asleep, almost anywhere and at inappropriate times). Characters performing demanding tasks such as engaging in combat or casting a spell may, when stressed, need to make DC 15 Concentration checks to stay awake and not put themselves in a dangerous situation.

Night Terrors: A sleeping character wakes after a few hours of sleep, usually screaming in terror. Pulse and breathing are rapid, pupils are dilated, and hair stands on end. The character is confused and hard to calm down. Night terrors are similar to ordinary nightmares, but much more intense and disruptive.

Somnambulism: Sleepwalking. As with night terrors, this behavior occurs in the first few hours of sleep. An episode may last up to 30 minutes. During the episode, the character’s face is blank and staring, and she can be roused only with difficulty. Once awake, she recalls nothing of the activity.

Somatoform Disorders

A somatoform disorder may be diagnosed when a character experiences physical symptoms that cannot be explained by an actual physical injury or disease.

Somatization Disorder: The character suffers from a physical ailment or diseaselike effect, with symptoms ranging from dizziness and impotence to blindness and intense pain. The Heal skill cannot identify any physical cause for the symptoms, and magical healing has no effect. The victim does not believe that her symptoms represent a specific disease. All attack rolls, saves, and checks take a -2 penalty.

Conversion Disorder: The character reports dysfunctions that suggest a physical disorder but, though they are involuntary, the symptoms actually provide a way for the victim to avoid something undesirable or a way to garner attention and caring, a condition called Munchausenism. Symptoms range from painful headaches to paralysis or blindness. With the condition known as Reverse Munchausenism, a character projects ill health onto others and may even arrange injuries or illnesses for them so that she can thereafter take care of them. All attack rolls, saves, and checks take a -2 penalty.

Hypochondriasis: Character believes she suffers from a serious disease. No physical cause for reported symptoms can be found, but the character continues to believe that the disease or condition exists, often with serious consequences to her normal life.

Body Dysmorphic Disorder: Character suffers from perceived flaws in appearance, usually of the face, or of the hips or legs. Behavior may alter in unexpected ways to cover up the flaws or to calm anxieties.

Substance Abuse Disorder

A character with a substance abuse disorder finds solace in using a drug, becomes addicted to it, and spends much time maintaining, concealing, and indulging the habit. Drugs include alcohol, amphetamines, cocaine, hallucinogens, marijuana, nicotine, opium (especially morphine and heroin), sedatives, and more fantastic substances present in the campaign world (see Horrific drugs).

A character under the sway of such a substance should feel the personal struggle daily. Will saving throws might be used to resist or succumb symbolically to cravings, especially just before periods of stress (for example, just before a confrontation or likely battle with evil cultists). All attack rolls, saves, and checks take a -2 morale penalty because of withdrawal symptoms. Sanity losses could occur from binges or bad trips. Some characters might find that drugs promote communication with alien entities and deities, and that dreams about them become ever more vivid and horrifying, Conversely, such substances might function as medications, deadening a character’s fears and offering temporary defenses against Sanity loss.

Other Disorders

Other disorders exist in common parlance, but most of these are actually symptoms or specific instances of disorders already mentioned above. These include quixotism (seeing the supernatural everywhere, even in the most mundane surroundings), panzaism (seeing the most extraordinary events as ordinary and rational), and megalomania (delusions of power, wealth, fame, and ability). Use or ignore these as suits your campaign, or invent new categories of madness to reflect the chaos that lies just below the brittle surface of Lovecraft’s world.

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