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World of d20d20 Modern Horror
It is my considered opinion that all RPG's should have Sanity and Knowledge (Forbidden Lore) (also known as Cthulhu Mythos) on the character sheets, just to make the players uncertain.
Tracking Sanity: Sanity is handled entirely by the GM. Maybe. At least you'll be told so.

This variant system allows you to introduce an element of dark horror into your d20 game. In campaigns using these rules, characters gain a new attribute called Sanity. This statistic functions like an ability score in some ways, but it has its own unique mechanics that represent the character’s descent from a stable and healthy mental state into confusion, dementia, and mental instability. As a character encounters monsters, witnesses horrible acts, masters forbidden knowledge, or casts spells, his Sanity score, and his corresponding ability to function as a normal member of his race, deteriorates. This gradual descent is balanced in part by the powers that characters gain each time they overcome a horrific foe or grow in skill and expertise, but even as those characters grow in power, they know or fear that an even greater peril lies ahead—the threat of becoming permanently insane.

Metagame Analysis: Sanity: Because it affects the way that characters interact with the creatures and objects that they encounter on their adventures in many different and profound ways, this variant, perhaps more than any other in Unearthed Arcana, can alter the entire feel of a campaign. If you adopt this variant in your campaign, the largest change will most likely be one of tone (this applies to an even greater extent if you adopt the entire Cthulhu Mythos that the variant is based on).
As in the Call of Cthulhu Roleplaying Game, characters feel more vulnerable, for no matter how powerful they become, the dark gods are always greater. Religion is not only a source of comfort or succor, but also a dangerous enemy. (In those games that use the Cthulhu Mythos, religion seldom provides any succor at all.) Characters are suspicious, even paranoid, for a seemingly innocent commoner could secretly serve a cult. And yet, with such dark challenges come the opportunities for greater heroism.

What Is Sanity?

Sanity is the natural mental state of ordinary life. Normal mental balance is endangered when characters confront horrors, entities, or activities that are shocking, unnatural, and bewildering. Such encounters cause a character to lose points from his Sanity score, which in turn risks temporary, indefinite, or permanent insanity. Mental stability and lost Sanity points can be restored, up to a point, but psychological scars may remain.

Insanity occurs if too many Sanity points are lost in too short a time. Insanity does not necessarily occur if Sanity points are low, but a lower Sanity score makes some forms of insanity more likely to occur after a character experiences an emotional shock. The character’s Sanity may be regained after a few minutes, recovered after a few months, or lost forever.

A character may regain Sanity points, and even increase her Sanity point maximum. However, increasing a character’s ranks in the Knowledge (Forbidden Lore) skill always lowers her maximum Sanity by an equal amount.

Forbidden Knowledge

The Sanity rules assume that some knowledge is so alien to human understanding that simply learning of its existence can shatter the psyche. While magic and nonhuman races form an everyday part of a d20 character’s life, even a seasoned adventurer cannot conquer or understand some things. Knowledge of these secrets and creatures is represented by a new skill that goes hand in hand with a character’s Sanity score: Knowledge (forbidden lore).

This type of knowledge permanently erodes a character’s ability to maintain a stable and sane outlook, and a character’s current Sanity can never be higher than 99 minus the modifier the character has in the Knowledge (Forbidden Lore) skill. This number (99 minus Knowledge (Forbidden Lore) ranks) is the character’s maximum Sanity.

Sanity Points

Sanity points measure the stability of a character’s mind. This attribute provides a way to define the sanity inherent in a character, the most stability a character can ever have, and the current level of sane rationality that a character preserves, even after numerous shocks and horrid revelations.

Sanity is measured in three ways: starting Sanity, current Sanity, and maximum Sanity. Starting and current Sanity cannot exceed maximum Sanity.

Starting Sanity

A character’s starting Sanity equals his Wisdom score multiplied by 5. This score represents a starting character’s current Sanity, as well as the upper limit of Sanity that can be restored by the Heal skill (see The Heal Skill and Mental Treatment, later in this section). After creation, a character’s current Sanity often fluctuates considerably and might never again match starting Sanity. A change in a character’s Wisdom score changes his starting Sanity in terms of what treatment with the Heal skill can restore. Current Sanity, however, does not change if Wisdom rises or falls.

Current Sanity

A character’s current Sanity score fluctuates almost as often as (and sometimes much more often than) his hit points.

Making a Sanity Check

When a character encounters a gruesome, unnatural, or supernatural situation, the GM may require the player to make a Sanity check using percentile dice (d%). The check succeeds if the result is equal to or less than the character’s current Sanity.

On a successful check, the character either loses no Sanity points or loses only a minimal amount. Potential Sanity loss is usually shown as two numbers or die rolls separated by a slash, such as 0/1d4. The number before the slash indicates the number of Sanity points lost if the Sanity check succeeds (in this case, none); the number after the slash indicates the number of Sanity points lost if the Sanity check fails (in this case, between 1 and 4 points).

A character’s current Sanity is also at risk when the character reads certain books, learns certain types of spells, and attempts to cast them. These Sanity losses are usually automatic (no Sanity check is allowed); the character who chooses to undertake the activity forfeits the indicated number of Sanity points.

In most cases, a new Sanity-shaking confrontation requires a new Sanity check. However, the GM always gets to decide when characters make Sanity checks. Confronting several horribly mangled corpses at one time or in rapid succession may call for just one Sanity check, while the same corpses encountered singly over the course of several game hours may require separate checks.

Going Insane

Losing more than a few Sanity points may cause a character to go insane, as described below. If a character’s Sanity score drops to 0 or lower, she begins the quick slide into permanent insanity. Each round, the character loses another point of Sanity. Once a character’s Sanity score reaches -10, she is hopelessly, incurably insane. The Heal skill can be used to stabilize a character on the threshold of permanent insanity; see The Heal Skill and Mental Treatment, below, for details.

A GM’s description of a Sanity-shaking situation should always justify the threat to a character’s well-being. Thus, a horde of frothing rats is horrifying, while a single ordinary rat usually is not (unless the character has an appropriate phobia, of course).

Maximum Sanity

Ranks in the Knowledge (Forbidden Lore) skill simulate a character’s comprehension of aspects of the dark creatures at the edges of reality. Once gained, this horrible knowledge is never forgotten, and the character consequently surrenders mental equilibrium. A character’s Sanity weakens as his comprehension of these hidden truths increases. Such is the way of the universe.

A character’s current Sanity can never be higher than 99 minus the character’s ranks in the Knowledge (forbidden lore) skill. This number (99 minus Knowledge (Forbidden Lore) ranks) is the character’s maximum Sanity.

Loss Of Sanity

Characters ordinarily lose Sanity in a few types of circumstances: when encountering something unimaginable, when suffering a severe shock, after casting a spell or when learning a new spell, when being affected by a certain type of magic or a particular spell, or when reading a forbidden tome.

Sanity Resistance

The Sanity mechanic was originally created to mimic the effect that the unspeakable horrors of the Cthulhu Mythos would have on normal folk from a world much like our own. Since d20 characters live in a world of magic and monsters, however, the GM might want to make them less susceptible to Sanity loss caused by encountering strange creatures (see Encountering the Unimaginable) by allowing them to have a measure of Sanity resistance, which is tied to one of two attributes.

Each character can be allowed to have Sanity resistance equal to his character level. Alternatively, each character can be allowed to have Sanity resistance equal to his Wisdom modifier. (Obviously, the second alternative will produce lower Sanity resistance figures in most cases.) This number is the amount of Sanity loss a character can ignore when he encounters a creature that requires a Sanity check.

The GM may decide that Sanity resistance also applies to certain kinds of severe shocks (although it might not apply to personally horrific experiences, such as seeing a close friend die) and to the casting or learning of spells.

Encountering the Unimaginable

When people perceive creatures and entities of unspeakable horror, this experience costs them some portion of their minds, since such creatures are intrinsically discomforting and repellent. We never lose awareness of their slimy, fetid, alien nature. This instinctive reaction is part and parcel of humans, elves, dwarves, and other humanoid races. In this category, we can include supernatural events or agents not always recognized as specifically devoted to these dark gods, such as hauntings, zombies, vampires, curses, and so on.

Table: Sanity Loss from Encounters
Monster Type Monster Size
Tiny Small Medium Large Huge Gargantuan Colossal
Aberration, dragon, ooze,
outsider, undead
1/1d4 1/1d4 1/1d6 1/1d10 1d4/1d10 1d6/1d10 1d6/2d10
Elemental, fey, plant, vermin 0/1d4 1/1d4 1/1d6 1/1d8 1/1d10 1d4/1d10 1d4/2d6
Construct, giant, magical beast,
monstrous humanoid
0/1 0/1d4 0/1d6 1/1d6 2/2d6 2/2d6 3/3d6
Animal, humanoid 0/0 0/11 0/11 0/1d41 0/1d4 0/1d4 0/1d6
1) Only animals or humanoids of truly bizarre or ferocious appearance force such a check.

The table provides some default Sanity loss values for encountering creatures, based on their type and size. These are only default values——the GM can and should adjust individual monsters he deems more or less horrible than others of their size. An aasimar, for instance, hardly presents a Sanity-shaking sight, and should probably be treated as a humanoid rather than an outsider. On the other hand, a vargouille——a Small outsider appearing much like a flying, bat-winged head——might provoke a much more visceral reaction than other Small outsiders.

In addition, certain types of monstrous behavior might force additional Sanity checks, much like those described under Severe Shocks, below. For instance, an aboleth is an unnerving sight, but watching one transform your best friend with it's slime should certainly force another check, with losses appropriate to the situation.

No character should need to make a Sanity check for encountering domesticated or otherwise commonplace animals. A monster character never loses Sanity for encountering others of its own race.

Severe Shocks

A shocking sight of a more mundane nature can also cost Sanity points. Severe shocks include witnessing an untimely or violent death, experiencing personal mutilation, losing social position, being the victim of treachery, or whatever else the Game Master decides is sufficiently extreme. The following list gives some examples of severe shocks, and the Sanity loss each one provokes.

Table: Sanity Loss from Situations
Sanity Lost Shocking Situation
0/1d2 Surprised to find mangled animal carcass
0/1d3 Surprised to find human corpse
0/1d3 Surprised to find human body part
0/1d4 Finding a stream flowing with blood
1/1d4+1 Finding a mangled human corpse
0/1d6 Awakening trapped in a coffin
0/1d6 Witnessing a friend’s violent death
1/1d6 Seeing a ghoul
1/1d6+1 Meeting someone you know to be dead
0/1d10 Undergoing severe torture
1/d10 Seeing a corpse rise from its grave
2/2d10+1 Seeing a gigantic severed head fall from the sky
1d10/d% Seeing an evil deity

Casting Spells

Magic relies on the physics of the true universe. By casting spells, characters visualize the unimaginable, warping their minds to follow alien ways of thought. These visualizations wound the mind. Although spellcasters expose themselves to such traumas voluntarily, they are shocks all the same.

Table: Sanity Loss from Spellcasting
Sanity Loss
Low Moderate Extreme
1st 1 2 1d6
2nd 2 4 2d6
3rd 3 6 3d6
4th 4 8 4d6
5th 5 10 5d6
6th 6 12 6d6
7th 7 14 7d6
8th 8 16 8d6
9th 9 18 9d6

In this variant, casting a spell drains a certain amount of Sanity. This rule represents the fact that spellcasting forces the mind into strange patterns and thought processes with which it is poorly equipped to deal. The GM can choose from the three options presented in the table below, deducting a low, moderate, or extreme number of Sanity points from a character who casts a spell. In a campaign featuring low Sanity loss, a spellcaster is rarely penalized for casting a spell, especially if the GM also chooses to give characters Sanity resistance (see the sidebar) in such cases. In a campaign featuring moderate Sanity loss, spellcasters face a slightly higher risk of insanity than members of other classes, even if they have Sanity resistance. When using this option, players should, for the most part, choose spellcasting levels only as multiclass options. In a campaign featuring extreme Sanity loss, spellcasters have a difficult time participating in adventures regularly because they find it hard to use their classes’ primary abilities without soon going insane.

In addition to the guidelines presented for each campaign option above, the GM is free to impose additional modifiers on the Sanity loss caused by spells of a certain type, a certain school, or even individual spells. Here are some example conditions that a GM could choose to incorporate into a game.

  • Abjurations cost 1 less Sanity point to cast.
  • Divine spells cost 5 additional Sanity points to cast.
  • Druids suffer only half the Sanity loss from spellcasting (round fractions up).
  • Healing spells drain no Sanity when cast.
  • The invisibility spell, and any variation thereof, costs 1 additional Sanity Point to cast.
  • Necromancy spells cost 2 additional Sanity points to cast.
  • Spellcasters of some classes follow the guidelines of one campaign option, while spellcasters of other classes follow the guidelines of another campaign option.

Learning Spells

Learning spells, like casting them, exposes a character to unknowable secrets and can damage and warp the mind. In this variant, whenever a spellcaster learns a new spell, he loses Sanity points. In most cases, the Sanity loss is equal to the spell’s level, but if the spell is included in a tome of forbidden knowledge (see below), the loss can be greater.

The rules for Sanity loss for learning spells work fine for wizards, sorcerers, and other arcane spellcasting classes that learn spells one at a time or in small groups, but this loss can easily overwhelm a cleric, druid, or other divine spellcaster who gains a new spellcasting level (thereby “learning” an entire level’s worth of new spells all at once). In such a case, the player and the GM should work together to determine a specific number of spells learned once access to a new spellcasting level is gained. When in doubt about how many spells to allow a spellcaster to learn at any given level, the spell acquisition rate of the wizard class serves as a good baseline.

GMs wanting to add Sanity rules to a magic-rich campaign, or those wishing to preserve more of the flavor of a normal d20 game, can allow any spellcaster to learn a small number of spells at each level without losing any Sanity. Sanity-Affecting Magic

The following types of magic and specific spells have different or additional effects when the Sanity variant is in use. For the effects of healing spells and magical means of recovering sanity, see Restoring Sanity with Magic, later in this section.

Fear Effects

Whenever a spell, creature, or other factor produces a fear effect that causes its target to become shaken, frightened, or panicked, replace the saving throw to avoid the effect (if applicable) with a Sanity check. On a failed check (and sometimes even on a successful one), the subject loses a number of Sanity points rather than experiencing the normal effect of the magic. The table below provides a summary of the Sanity loss associated with each spell that has the fear descriptor:

Table: Sanity Loss from Fear Effects
Spell Sanity Loss on Failed Check Sanity Loss on Successful Check
Bane1 — —
Cause fear 1d6 1
Doom 1d6 —
Fear 2d6 1
Phantasmal killer2 — —
Scare 1d6 1
Symbol of fear 2d6 —
Weird2 — —

1) Bane works normally because its effect is less severe than that of the shaken condition. In this variant, remove fear does not automatically suppress an existing fear effect on its subjects, but if it is cast on a creature that lost Sanity because of a fear effect within the last 24 hours, that Sanity loss is halved (to a minimum of 1 point) and the creature’s current Sanity is adjusted accordingly.

2) Phantasmal killer and weird work normally because those spells do not produce a shaken, frightened, or panicked effect. (The GM could rule that a Sanity check takes the place of the Fortitude save to avoid dying from fear; in such a case, failing the check results in permanent insanity.)


Illusions, when they are believed, cause Sanity loss just as if the real horrific monster or event were present. The GM can reduce the Sanity loss caused by illusions (or eliminate it entirely) if such spells appear frequently in the campaign.

Bestow Curse

When using the Sanity variant, this spell can cause a Sanity check rather than a Will save. If the victim fails the Sanity check, he loses 3d6 points of Sanity. Unlike normal Sanity loss, this number is also subtracted from the character’s maximum Sanity. Magic that removes the curse (such as remove curse or break enchantment) can restore the character’s normal maximum Sanity, but separate magic or the use of the Heal skill is required to restore the character’s current Sanity.

Contact Other Plane

When using the Sanity variant, characters casting this spell risk a lost of Sanity instead of Intelligence and Charisma. Whenever a character casts this spell, she must make a Sanity check. If the check fails, the character loses Sanity depending on the plane that the character was trying to contact, according to the table below. Unlike the Intelligence and Charisma reduction caused by the normal version of this spell, the Sanity loss does not go away after a week—the loss is permanent until restored by another spell or through the use of the Heal skill.

Table: Sanity Loss from Contact Other Plane
Plane Contacted Sanity Loss
Elemental Plane (appropriate) 1
Positive/Negative Energy Plane 1
Astral Plane 2
Outer Plane (demideity) 1d6
Outer Plane (lesser deity) 2d6
Outer Plane (intermediate deity) 3d6
Outer Plane (greater deity) 4d6


When using the Sanity variant, replace this spell’s XP cost with a Sanity check (1d6/3d6), made as a free action immediately after the spell’s duration expires. Insanity: Instead of experiencing this spell’s normal effect, characters who fail the saving throw to resist the spell become permanently insane as described in this variant (but suffer no Sanity loss).

Moment of Prescience

In addition to the spell’s normal benefits, a character with an active moment of prescience effect can make one Sanity check as if his current Sanity equaled his maximum Sanity. The character need not use the effect on the first Sanity check he is required to make, but he must choose whether or not to use this benefit before making any Sanity check during the spell’s duration.


In addition to the spell’s normal effect, the caster can sense whenever the subject suffers Sanity loss, temporary insanity, indefinite insanity, or permanent insanity during the spell’s duration.

Summon Monster

If a character summons a monster that causes Sanity loss by means of a summon monster, summon nature’s ally, planar binding, or planar ally spell, he suffers the usual Sanity loss for casting the spell and must also make a Sanity check because of the monster’s presence.

Symbol of Insanity

Instead of experiencing this spell’s normal effect, characters who fail the saving throw to resist the symbol become permanently insane as described in this variant (but suffer no Sanity loss).

Reading Forbidden Tomes

Obscure tomes add ranks to a character’s Knowledge (Forbidden Lore) skill and teach arcane spells. Studying and comprehending these books causes all that we know to become like shadows. The burning power of a greater reality seizes the soul. Whether we try to retreat from the experience or hunger greedily for more, it destroys our confidence in what we once believed, opening us up to the all-encompassing truths of dark deities.

For each such book encountered, the GM must set the examination period, the Knowledge (arcana) DC to understand it, the number of spells contained in it, the Sanity loss that occurs upon beginning the examination, the Sanity loss that occurs upon completion of the examination, and the ranks of Knowledge (Forbidden Lore) gained from studying the book. While the GM is free to set these parameters at any values that he feels are appropriate for the campaign or adventure, the table provides some suggested combinations of each of these parameters.

Table: Sanity Loss from Reading Sample Tomes
Examination Period Knowledge (arcana) DC to Understand Tome Spells Contained Initial Sanity Loss Sanity Loss upon Completion Knowledge (forbidden lore) ranks gained
1 week 20 0 1 1d4 1
1 week 20 1 1d4 1d4 1
1 week 25 2 1d4 2d6 1
2 weeks 25 1d4 1d6 2d6 2
2 weeks 25 1d6 1d10 2d6 2
2 weeks 25 3 1d6 2d6 2
2 weeks 30 1d6+1 1d6 2d6 3
3 weeks 20 1d4+1 1d10 2d6 2
3 weeks 25 1d6 1d6 2d10 2
3 weeks 30 1d4+5 1d10 3d6 3

Getting Used To Awfulness

Never underestimate the ability of the sentient mind to adapt, even to the most horrific experiences. Reading and rereading the same bit of disturbing text or seeing the same horrible image over and over eventually provokes no further loss of Sanity. Within a reasonable interval of play, usually a single session of the game, characters should not lose more Sanity points for seeing monsters of a particular sort than the maximum possible points a character could lose from seeing one such monster. For instance, the Sanity loss for seeing a single human zombie is 1/1d6. Thus, in the same game day or in the same play session, no character should lose more than 6 Sanity points for seeing any number of zombies. Keep in mind that the interpretation of “reasonable interval” must vary by GM and situation. When it feels right, the GM should rule that the horror is renewed and points must be lost again.

Learning or casting spells never becomes a normal occurrence. No matter how many times a character casts a spell, no matter what the time interval between castings may be, the Sanity loss is always the same. This point is also true for anything that a character does willingly. For example, if brutally murdering a friend costs 2/1d10 Sanity, this loss is incurred each time, even if the character loses the maximum possible points (10) after the first such murder he commits.

Variant Rule: Insane Insight

At the GM’s option, a character who has just gone insane may have an insight into the situation or entity that provoked the insanity. The player needs to make a DC 15 Wisdom check to gain the insight. Information provided by this sudden burst of awareness is up to the GM, but it may include something about a creature’s origin or a fact about its nature (feeding habits, natural habitat, weakness), a clue to the identity of a murderer at a murder scene, or some hint at a location of great importance.

Types Of Insanity

Character insanity is induced by a swift succession of shocking experiences or ghastly revelations, events usually connected with dark gods, creatures from the Outer Planes, or powerful spellcasting.

Horrifying encounters can result in one of three states of mental unbalance: temporary, indefinite, and permanent insanity. The first two, temporary insanity and indefinite insanity, can be cured. The third, permanent insanity, results when a character’s Sanity points are reduced to -10 or lower. This condition cannot be cured.

Temporary Insanity

Whenever a character loses Sanity points equal to one-half her Wisdom score from a single episode of Sanity loss, she has experienced enough of a shock that the GM must ask for a Sanity check. If the check fails, the character realizes the full significance of what she saw or experienced and goes temporarily insane. If the check succeeds, the character does not go insane, but she may not clearly remember what she experienced (a trick the mind plays to protect itself).

Temporary insanity might last for a few minutes or a few days. Perhaps the character acquires a phobia or fetish befitting the situation, faints, becomes hysterical, or suffers nervous twitches, but she can still respond rationally enough to run away or hide from a threat.

A character suffering from temporary insanity remains in this state for either a number of rounds or a number of hours; roll d% and consult Table: Duration of Temporary Insanity to see whether the insanity is short-term or long-term. After determining the duration of the insanity, roll d% and consult the proper table to identify the specific effect of the insanity. The GM must describe the effect so that the player can roleplay it accordingly.

Table: Duration of Temporary Insanity
d% Temporary Insanity Type Duration
01-80 Short-term 1d10+4 rounds
81-100 Long-term 1d10×10 hours
Table: Short-Term Temporary Insanity Effects
d% Effect
01-20 Character faints (can be awakened by vigorous action taking 1 round; thereafter, character is shaken until duration expires).
21-30 Character has a screaming fit.
31-40 Character flees in panic.
41-50 Character shows physical hysterics or emotional outburst (laughing, crying, and so on).
51-55 Character babbles in incoherent rapid speech or in logorrhea (a torrent of coherent speech).
56-60 Character gripped by intense phobia, perhaps rooting her to the spot.
61-65 Character becomes homicidal, dealing harm to nearest person as efficiently as possible.
66-70 Character has hallucinations or delusions (details at the discretion of the GM).
71-75 Character gripped with echopraxia or echolalia (saying or doing whatever those nearby say or do).
76-80 Character gripped with strange or deviant eating desire (dirt, slime, cannibalism, and so on).
81-90 Character falls into a stupor (assumes fetal position, oblivious to events around her).
91-99 Character becomes catatonic (can stand but has no will or interest; may be led or forced to simple actions but takes no independent action).
100 Roll on Table: Long-Term Temporary Insanity Effects.
Table: Long-Term Temporary Insanity Effects
d% Effect
01-10 Character performs compulsive rituals (washing hands constantly, praying, walking in a particular rhythm, never stepping on cracks, constantly checking to see if crossbow is loaded, and so on).
11-20 Character has hallucinations or delusions (details at the discretion of the GM).
21-30 Character becomes paranoid.
31-40 Character gripped with severe phobia (refuses to approach object of phobia except on successful DC 20 Will save).
41-45 Character has aberrant sexual desires (exhibitionism, nymphomania or satyriasis, teratophilia, necrophilia, and so on).
46-55 Character develops an attachment to a “lucky charm” (embraces object, type of object, or person as a safety blanket) and cannot function without it.
56-65 Character develops psychosomatic blindness, deafness, or the loss of the use of a limb or limbs.
66-75 Character has uncontrollable tics or tremors (-4 penalty on all attack rolls, checks, and saves, except those purely mental in nature).
76-85 Character has amnesia (memories of intimates usually lost first; Knowledge skills useless).
86-90 Character has bouts of reactive psychosis (incoherence, delusions, aberrant behavior, and/or hallucinations).
91-95 Character loses ability to communicate via speech or writing.
96-100 Character becomes catatonic (can stand but has no will or interest; may be led or forced into simple actions but takes no independent action).

Successful application of the Heal skill (see The Heal Skill and Mental Treatment, below) may alleviate or erase temporary insanity.

Temporary insanity ends either when the duration rolled has elapsed, or earlier if the GM considers it appropriate to do so.

After an episode of temporary insanity ends, traces or even profound evidence of the experience should remain. No reason exists why, for instance, a phobia should depart from someone’s mind as quickly as a warrior draws his sword. What remains behind after a brief episode of temporary insanity should exert a pervasive influence on the character. The character may still be a bit batty, but her conscious mind once again runs the show.

As a variant rule, if the amount of Sanity lost exceeds the character’s current Wisdom score, consider the temporary insanity to always be of the long-term variety.

Indefinite Insanity

If a character loses 20% (one-fifth) or more of her current Sanity points in the space of 1 hour, she goes indefinitely insane. The GM judges when the impact of events calls for such a measure. Some GMs never apply the concept to more than the result of a single roll, since this state can remove characters from play for extended periods. An episode of indefinite insanity lasts for 1d6 game months (or as the GM dictates). Symptoms of indefinite insanity may not be immediately apparent (which may give the GM additional time to decide what the effects of such a bout of insanity might be).

Table: Random Indefinite Insanity is provided as an aid to selecting what form a character’s indefinite insanity takes. (The mental disorders mentioned on this table are explained later in this section.) Many GMs prefer to choose an appropriate way for the insanity to manifest, based on the circumstances that provoked it. It’s also a good idea to consult with the player of the afflicted character to see what sort of mental malady the player wishes to roleplay.

Table: Random Indefinite Insanity
d% Mental Disorder Type
01–-15 Anxiety (includes severe phobias)
16–-20 Dissociative (amnesia, multiple personalities)
21–-25 Eating (anorexia, bulimia)
26–-30 Impulse control (compulsions)
31–-35 Mood (manic/depressive)
36–-45 Personality (various neuroses)
46–-50 Psychosexual (sadism, nymphomania)
51–-55 Psychospecies
56–-70 Schizophrenia/psychotic (delusions, hallucinations, paranoia, catatonia)
71–-80 Sleep (night terrors, sleepwalking)
81–-85 Somatoform (psychosomatic conditions)
86–-95 Substance abuse (alcoholic, drug addict)
96–-100 Other (megalomania, quixotism, panzaism)

The state of indefinite insanity is encompassing and incapacitating. For instance, a schizophrenic may be able to walk the streets while babbling and gesticulating, find rudimentary shelter, and beg for enough food to survive, but most of the business of the mind has departed into itself: She cannot fully interact with friends, family, and acquaintances. Conversation, cooperation, and all sense of personal regard have vanished from her psyche.

It is possible for characters with indefinite insanity to continue to be played as active characters, depending on the form their madness takes. The character may still attempt to stumble madly through the rest of an adventure. However, with her weakened grasp on reality, she is most likely a danger to herself and others.

As a general rule, a character suffering from indefinite insanity should be removed from active play until she recovers. At the GM’s discretion, the player of the character might be allowed to use a temporary character until the end of the story. Whether this “stand-in” character is an incidental NPC in the adventure, a character of the same level as the rest of the group, one or two levels below the rest of the characters, or even a 1st-level character, is up to the GM. Different GMs have different ways of handling this transition.

If a character goes indefinitely insane near the end of an adventure, the GM may decide to set the next adventure to begin after the insane character has recovered.

Characters suffering from indefinite insanity are in limbo, unable to help themselves or others. The Heal skill can be used to restore Sanity points during this period, but the underlying insanity remains.

After recovery, a victim retains definite traces of madness. For example, even though a character knows he is no longer insane, she might be deathly afraid of going to sleep if her insanity manifested itself in the form of terrifying nightmares. The character is in control of her actions, but the experience of insanity has changed her, perhaps forever.

Permanent Insanity

A character whose Sanity score falls to -10 goes permanently insane. The character becomes an NPC under the control of the Game Master.

A character with permanent insanity may be reduced to a raving lunatic or may be outwardly indistinguishable from a normal person; either way, she is inwardly corrupted by the pursuit of knowledge and power. Some of the most dangerous cultists in the world are characters who have become permanently insane, been corrupted by forbidden knowledge, and “gone over to the other side.”

A character might be driven permanently insane by forces other than dark gods or forbidden knowledge. In such cases, moral corruption need not necessarily occur. The GM might decide to consider different sorts of permanent insanity, rolling randomly or choosing from among the mental disorders on Table: Random Indefinite Insanity, above.

A character who has gone permanently insane can never be normal again (in some campaigns, a permanently insane character can be cured with the aid of powerful magic). She is forever lost in her own world. This need not mean a lifetime locked away from society, merely that the character has retreated so far from reality that normal mental functions can never be restored. She might be able to lead, within restricted bounds, a more or less normal life if kept away from the stimulus that triggers strong responses in her individual case. Yet a relapse may come quickly. Her calm facade can be destroyed in seconds if even the smallest reminder of what it was that drove her mad disturbs her fragile equilibrium. In any event, the eventual fate of a permanently insane character is a matter for individual Game Masters and players to decide.

Gaining Or Recovering Sanity

A character’s Sanity score can increase during the events of a campaign. Although a character’s Sanity score can never exceed 99 minus her Knowledge (forbidden lore) ranks, her maximum Sanity and current Sanity can exceed her starting Sanity.

Level Advancement

A character’s current Sanity can become higher than her starting Sanity as a result of gained levels: Whenever a character gains a new level, she rolls 1d6 and adds the result to her current Sanity. Some GMs may feel such self-improvement to be antithetical to this variant’s dark tone, and thus may not allow it. Others may allow it if the player can roll over her character’s current Sanity points after the character gains a level. Most Game Masters should find the question to be of no consequence, since characters continue to go insane regardless of how many Sanity points they gain. This is a point for players to be aware of, but not to worry about.

Story Awards

The GM may decide to award increases in character’s current Sanity if they foil a great horror, a demonic plan, or some other nefarious enterprise.

The Heal Skill And Mental Treatment

The Sanity rules presented here provide a new use for the Heal skill, allowing trained healers to help characters recover lost Sanity points. The DC and effect of a Heal check made to restore lost Sanity depend on whether the therapist is trying to offer immediate care or long-term care.

Immediate Care

When someone suffers an episode of temporary insanity, a therapist can bring him out of it—calming his terror, snapping him out of his stupor, or doing whatever else is needed to restore the patient to the state she was in before the temporary insanity—by making a DC 15 Heal check as a full-round action.

A therapist can also use immediate care to stabilize the Sanity score of a character whose current Sanity is between -1 and -9. On a successful DC 15 check (requiring a full-round action), the character’s Sanity score improves to 0.

Long-Term Care

Providing long-term care means treating a mentally disturbed person for a day or more in a place away from stress and distractions. A therapist must spend 1d4 hours per day doing nothing but talking to the patient. If the therapist makes a DC 20 Heal check at the end of this time, the patient recovers 1 Sanity point. A therapist can tend up to six patients at a time; each patient beyond the first adds 1 hour to the total time per day that must be devoted to therapy. The check must be made each day for each patient. A roll of 1 on any of these Heal checks indicates that the patient loses 1 point of Sanity that day, as she regresses mentally due to horrors suddenly remembered.

Variant —Knowledge (Mental Therapy)

A new skill called Knowledge (mental therapy) can serve as the primary way to treat those who have suffered Sanity loss. Knowledge (mental therapy) is a Wisdom-based skill that cannot be used untrained. If you use this variant, characters with the Heal skill can only offer immediate care, and cannot offer long-term care. The Knowledge (mental therapy) skill allows both types of treatment.

Note: If magical means of restoring Sanity are present in the campaign, the Knowledge (mental therapy) skill is generally not worth including as a separate skill, because characters are better off simply using magic rather than devoting precious skill points to such a narrow-focus skill. If magic cannot restore Sanity, the ability to restore Sanity by other means is much more important, and Knowledge (mental therapy) should probably exist as a separate skill.

Mental Therapy

To give useful mental therapy, a therapist must have the Heal skill. Intensive treatment can return Sanity points to a troubled character. However, Sanity points restored in this manner can never cause the patient’s Sanity score to exceed her starting Sanity or maximum Sanity, whichever is lower. A character can have only one healer at a time. See The Heal Skill and Mental Treatment sidebar for a detailed description of how this works.

Such treatment can also be used to help a character snap out of an episode of temporary insanity (for example, from an acute panic attack). It does not speed recovery from indefinite insanity, but it can strengthen a character by increasing her Sanity points.

Recovery from indefinite insanity only comes with time (typically, 1d6 months). It is not dependent upon the character’s Sanity points and is not connected to them. A character can be sane with 24 Sanity points and insane while possessing 77 Sanity points.

Restoring Sanity with Magic

The way that Sanity loss and magic healing interact can greatly affect the feel of your game. At one extreme, the GM can rule that magic can easily cure Sanity loss, in which case Sanity becomes little more than a specialized version of “mental hit points” that includes some neat side effects (insanity). In such a case, characters can usually restore themselves to full Sanity with a day or two of rest and spellcasting.

At the other extreme, the campaign might be structured so that magical healing can do little or nothing to restore Sanity, and even powerful divine spellcasters capable of curing the most deadly physical malady shy away from those encounters that might drain away Sanity points. The spells that can potentially restore Sanity points are discussed below. The GM should feel free to choose which of these spell effects are present in the game, but once established, these effects should not be changed in mid-campaign.

Atonement: Although this spell does not usually restore Sanity, it can be used in those rare cases when a character’s own actions inadvertently lead to an evil act that causes the character to lose Sanity points. If a quest or geas is combined with the atonement spell, Sanity points are not restored until the task is completed. A successful use of the atonement spell can restore all Sanity lost through the direct result of the evil acts for which the character atones.

Calm Emotions: This spell cannot restore Sanity directly, but it can temporarily mitigate the effects of temporary or permanent insanity. While the spell is in effect, the targets act calmly and ignore behavior changes caused by Sanity loss.

Heal: In addition to its normal effects, heal restores 10 Sanity points and removes all forms of temporary insanity.

Mind Blank: While the spell is in effect, the subject is immune to Sanity loss.

Miracle: This spell can restore a character to maximum Sanity even if his current Sanity has dropped to -10. Miracle even heals permanent insanity.

Restoration: If the caster chooses, restoration can restore 1d6 Sanity points per two levels to the target creature (max 5d6) instead of having its normal effect.

Restoration, Greater: If the caster chooses, greater restoration can restore the target creature to its maximum Sanity instead of having its normal effect.

Restoration, Lesser: If the caster chooses, lesser restoration can restore 1d4 Sanity points to the subject instead of having its normal effect.

Wish: This spell can restore a character to maximum Sanity even if his current Sanity has dropped to -10. Wish even heals permanent insanity.

Wish, Limited: This spell can restore a character to maximum Sanity even if his current Sanity has dropped to -10. Limited wish does not heal permanent insanity.

Alchemical Treatments

In the real world, psychiatric drugs play a key role in the modern treatment of many mental disorders. Although psychiatric drugs were administered to patients in the early part of the 20th century, only in the 1940s and later were they broadly and consistently effective in treating the symptoms of emotional trauma.

As long as a character can afford the correct herbs and alchemical substances and is able to ingest them, the symptoms of indefinite insanity can be ignored. Ingesting these alchemical substances and drugs does not make a character immune or even particularly resistant to further Sanity losses. A DC 25 Craft (alchemy) check is needed to accurately prepare the correct herbs and substances and administer the correct dosage.

Long-term alchemical treatment can restore lost Sanity points, just as use of the Heal skill can. For each month the character takes an accurately prescribed psychiatric medication, she regains 1d3 Sanity points. As with treatment through the Heal skill, long-term drug therapy can never raise a character’s current Sanity above her starting Sanity.

A character cannot regain Sanity from both treatment with the Heal skill and alchemical treatment in the same month.

Some horrific drugs also have some uses in treating insanity.

Treatment Of Insanity

Temporary insanity ends so quickly that schedules of treatment are essentially pointless; it runs its course soon enough that one merely need protect a deranged character from further upset or harm. On the other hand, treatment of permanent insanity has no real meaning. By definition, a permanently insane character never recovers, no matter how good the therapist or the facility. Thus, indefinite insanity is the only form of mental illness that might be addressed by intervention and treatment.

After 1d6 months, if undisturbed by further trauma and with the agreement of the Game Master, an indefinitely insane character finds enough mental balance to reenter the world. Three kinds of nonmagical care may help the character regain Sanity points during this recovery period. When choosing among them, the GM and player should consider the character’s resources, her friends and relatives, and how wisely she has behaved in the past. In most campaigns, the magical treatments described above (see Restoring Sanity with Magic) allow the character to reenter play after a shorter time or with less expense.

Private Care

The best care available is at home or in some friendly place (perhaps a small church or the home of a wealthy friend) where nursing can be tender, considerate, and undistracted by the needs of competing patients.

If mental healing or alchemical medications are available, roll d% for each game month that one or the other is used. A result of 01-95 is a success: Add 1d3 Sanity points for either mental therapy or alchemical medications, whichever is used (a character cannot benefit from both in the same month). On a result of 96-100, the healer fumbles the diagnosis or the character rejects the alchemical treatments. She loses 1d6 Sanity points, and no progress is made that month.


The next best alternative to private care is commitment to a good insane asylum, but these are extremely rare in most d20 campaigns, if they are present at all. GMs are free to rule that institutionalization is simply not available.

In those campaigns that include such institutions (usually located within the bounds of a temple devoted to a deity of healing), asylums may be said to have an advantage over home care in that they are relatively cheap or even a free service provided by a government or a powerful church. These institutions are of uneven quality, however, and some may be potentially harmful. Some are creative places of experiment and magic-assisted therapy, while others offer mere confinement. In any setting, concentrated and nourishing treatment by strangers is rare.

Therapy using the Heal skill is usually the only treatment available, but in most cases, primitive institutions offer no treatment at all. Sometimes an institution can convey an uncaring sense that undermines the useful effects of alchemical medications, leaving the character with a sense of anger and loss. He is likely to be distrustful of the organization and its motives. Escape attempts are common by inmates, even in the most enlightened fantasy settings.

Roll d% for each game month a character is in the care of an institution. A result of 01-95 is a success; add 1d3 Sanity points if therapy with the Heal skill was available, or 1 Sanity point if no treatment was present. On a result of 96-100, the character rebels against the environment. He loses 1d6 Sanity points, and no progress can be made that month.

Wandering and Homeless

If no care is available, an insane character may become a wandering derelict struggling for survival. Such a wanderer gains no Sanity points unless he is able to join a group of the homeless and find at least one friend among them. To find a friend after joining such a group, the character can make a DC 15 Charisma check once per month. If a friend appears, the character recovers 1 Sanity point per game month thereafter.

For each game month during which an insane character lives as a derelict, roll d%. On a result of 01-95, the character survives. On a result of 96-100, the character dies as the result of disease, exposure, or violence.

Modern Horror

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