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.

Knowledge (Forbidden Lore) (None)

You know That Which Should Not Be Known. You have had horrible supernatural experiences and read forbidden tomes, learning truly dark secrets that have challenged everything you thought you knew. Since these revelations defy logic or commonly accepted fact, it does not matter how intelligent or wise you are when using this skill—only how much exposure to these dark secrets themselves you have experienced.


Answering a question about the horrible deities and secrets that lurk at the edges of reality has a DC of 10 (for really easy questions), 15 (for elementary questions), or 20 to 30 (for difficult or really tough questions). Unlike in other fields of study, there are almost no really easy questions associated with this dark knowledge.

You can use this skill to identify monsters and their special powers or vulnerabilities. In general, the DC of such a check equals 10 + the monster’s HD. A successful check allows you to remember a bit of useful information about that monster. For every 5 points by which your check result exceeds the DC, the GM can give another piece of useful information.

The GM can decide which monsters are subject to the Knowledge (forbidden lore) skill and which monsters are subject to one of the standard Knowledge skills. For example, the GM may rule that Knowledge (the planes) is still the relevant skill for learning or knowing about outsiders, rather than allowing them to be iedntified by Knowledge (forbidden lore). However, in most campaigns that use the Sanity variant, aberrations and oozes should be able to be identified by Knowledge (forbidden lore) rather than by Knowledge (arcana) and Knowledge (dungeoneering) respectively.


Usually none. In most cases, making a Knowledge check doesn’t take an action—you simply know the answer or you don’t.

Try Again

No. The check represents what you know, and thinking about a topic a second time doesn’t let you know something that you never learned in the first place.


You cannot gain ranks in this skill by spending skill points. You can only gain ranks by reading forbidden tomes or having experiences with horrible creatures. Each rank you gain in this skill permanently reduces your maximum Sanity by 1 point: The more you know about the horrible truths underlying reality, the less capable you are of leading a normal life.

A character’s first episode of insanity (that is, an occurrence of temporary or indefinite insanity) bestows 2 ranks in the Knowledge (forbidden lore) skill, thereby lowering his maximum Sanity by 2 points. Each time a character fails a Sanity check and endures another episode of insanity, he gains an additional rank in Knowledge (forbidden lore).

For example, Caldark has 1 rank of Knowledge (forbidden lore) after reading a strange manuscript. She then steps outside, sees a chaos beast, and goes indefinitely insane, her raving mind failing to understand the strange creature she has encountered. Since she has never gone insane before, her player adds 2 ranks of Knowledge (forbidden lore) to Caldark’s character sheet. Now Caldark’s Maximum Sanity is 96 (99 minus 3 ranks of Knowledge [forbidden lore]).

You cannot take the Knowledge (forbidden lore) skill during character creation. However, the skill has no maximum rank; your level does not limit the number of ranks in Knowledge (forbidden lore) that you can acquire.

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 Table: Sanity Loss from Creatures) 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 Creatures 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.

In most d20 games, no character should need to make a Sanity check when encountering an elf, dwarf, or other standard humanoid race, or for encountering domesticated or otherwise commonplace animals. In some cases, even humanoid races such as orcs and goblins might be so common as to not cause Sanity loss either.

Specific Monsters and Sanity

Some monsters have additional or variant special abilities when using the Sanity variant.


The allip’s madness ability causes the loss of 2d6 Sanity points rather than the normal effect.


The derro’s madness ability protects these creatures from any further Sanity loss. Sane derro (especially derro player characters) track Sanity points normally.

Monstrous Characters and Sanity

In most cases, the GM does not need to keep track of a monster’s Sanity score, but sometimes, especially when in the hands of a player, monsters need Sanity scores just as other characters do.

Although most campaigns that use the Sanity variant limit players to creating characters from the standard player character races, it’s still easy to envision a world where one or two monstrous races are so common or so integrated into the culture of other races that the GM wants to present them as viable player character options. In these cases, the monsters available as player character races should never provoke a Sanity loss from other characters or NPCs, and these creatures should have a Sanity score and track their Sanity losses just like characters made with the standard PC races. A monster should never lose Sanity for seeing others of its race (spectres don’t lose Sanity when encountering other spectres, and so on). In all cases, what causes Sanity loss for a specific creature is in the hands of the GM.

Table: Sanity Loss from Creatures
Monster Type Monster Size
Up to Tiny Small Medium Large Huge Gargantuan Colossal
  1. Only animals or humanoids of truly bizarre or ferocious appearance force such a check.
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 0/01 0/11 0/11 0/1d41 0/1d4 0/1d4 0/1d6

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.

Sanity Lost1 Shocking Situation
  1. Loss on a successful check/loss on a failed check.
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

Table: Sanity Loss from Spellcasting
Sanity Loss
Sanity Loss
Sanity Loss
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

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.

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.

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
Table: Sanity Loss from Fear Effects
Spell Sanity Loss on
Failed Check
Sanity Loss on
Successful Check
  1. Bane works normally because its effect is less severe than that of the shaken condition.
  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.)
Cause fear 1d6 1
Doom 1d6
Fear 2d6 1
Phantasmal killer2
Scare 1d6 1
Symbol of fear 2d6

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:

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.


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
Table: Contact Other Plane
Plane 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, 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.


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, Table: Example Forbidden Tomes provides some suggested combinations of each of these parameters.

Table: Example Forbidden Tomes
Knowledge (arcana) DC
to Understand Tome
Number of Spells
Contained in Tome
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 6-8: 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 either Table 6-9 or 6-10 to identify the specific effect of the insanity. The GM must describe the effect so that the player can roleplay it accordingly.

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 on Table 6-8 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.

Table 6-8: Duration of Temporary Insanity
d% Temporary Insanity Type Duration
01-80 Short-term 1d10+4 rounds
81-100 Long-term 1d10×10 hours
Table 6-9: 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 6-10: Long-Term Temporary Insanity Effects.
Table 6-10: 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).

Indefinite Insanity

Table 6-11: 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)

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 6-11: 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.

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 6-11: 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.


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.


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.


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.


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


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.


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.

In a fantasy game, the GM should decide whether rare herbs and alchemical substances can provide the same benefits that modern psychiatric drugs can deliver. It is quite believable, for example, that the Red Wizards of Thay in the FORGOTTEN REALMS Campaign Setting discovered alchemical means of isolating substances that affect the mind in profound ways, offering many of the same benefits of modern medicine. Therefore, the GM need only decide how easily he wants characters to overcome Sanity loss and insanity effects. Once the desired tone of the campaign is known, the GM can determine whether alchemical treatment is available. The Sanity variant assumes that skilled alchemists can create substances that offer the same benefits that psychiatric drugs can provide.

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.

Drugs and Sanity

Drugs in the d20 game follow many of the same rules as poisons, allowing the imbiber saving throws to resist their initial and secondary effects. Delay poison, neutralize poison, and similar effects negate or end a drug’s effects, but they do not restore hit points, ability damage, or other damage caused by the substance.

A creature that willingly takes a drug automatically fails both saving throws. It is not possible to intentionally fail the initial save but attempt to save against the secondary effect, or vice versa. Save DCs are provided for situations in which a character is unwillingly drugged.

Drugs also have some uses in treating insanity. The drugs described below all affect a character’s Sanity to some extent.

For more details on drugs and advice on appropriate inclusion of drugs in a campaign, see Book of Vile Darkness or Lords of Darkness.

Sample Drugs

Table: Drugs
Name Type Price Craft
  1. Discussed in the following section.
Arthorvin Ingested DC 12 5 gp 25 Low
Carthagu Ingested DC 13 5 gp 25 Low
Mertoran leaf Ingested DC 13 10 gp 25 Negligible
Zixalix Ingested DC 16 15 gp 25 Medium

Below are examples of drugs that can be introduced into a campaign; many of them are effective against some sorts of mental disorders. Table: Drugs provides some specifics for each drug, and the text description for each one provides the following additional information.

Initial Effect

The effect of the drug if the initial Fortitude saving throw is failed.

Secondary Effect

The effect of the drug if the secondary Fortitude saving throw is failed 1 minute after ingestion.

Side Effect

The side effect (if any) that occurs immediately upon taking the drug.


What (if anything) constitutes an overdose and its effect on the character.


A fragrant gray powder made from rare magical plants, the drug called arthorvin is an appropriate alchemical treatment for anxiety, mood disorders, and dissociative disorders.

Initial Effect

1 point of Charisma damage.

Secondary Effect

The user is in a calm, peaceful mental state for 2d4 hours and gains a +1 alchemical bonus on Will saves.

Side Effect

Arthorvin causes a general dulling of the imbiber’s emotions and reactions. While the drug is in effect, the user takes a -1 penalty on all initiative checks.




Carthagu is a thin green tea served warm. It is an appropriate alchemical treatment for impulse control problems, eating disorders, and sleep disorders.

Initial Effect

2 points of Strength damage.

Secondary Effect

Carthagu soothes a wide range of mental disorders, providing relief from the symptoms of the indicated disorders for up to 8 hours.

Side Effect




Mertoran Leaf

When mertoran leaf is dried, treated, and chewed, it provides appropriate alchemical treatment for personality disorders, and substance abuse disorders.

Initial Effect

1 point of Dexterity damage.

Secondary Effect

The user becomes more confident, gaining a +2 alchemical bonus to Charisma for 1 hour.

Side Effect

While the drug is in effect and for 12 hours thereafter, mertoran leaf relieves the most severe symptoms of the listed disorders.




A potent combination of many rare herbs and alchemical substances, zixalix provides appropriate alchemical treatment for somatoform disorders, psychotic disorders (including schizophrenia), and psychosexual disorders.

Initial Effect

1d4 points of Intelligence damage.

Secondary Effect

Zixalix staves off the most severe symptoms of the indicated disorders.

Side Effect



If more than three doses are taken in a 24-hour period, the imbiber takes 1d4 points of Constitution damage.

Drug Addiction

Table: Addictions
Negligible 4 1 day 1d3-2 Dex (can be 0)
Low 6 10 days 1d3 Dex
Medium 10 5 days 1d4 Dex, 1d4 Wis
High 14 1 day 1d6 Dex, 1d6 Wis, 1d6 Con
Extreme 25 1 day 1d8 Dex, 1d8 Wis, 1d6 Con, 1d6 Str

Drug addiction functions much like diseases. The characteristics of certain forms of addiction are summarized on the table below. Upon initial exposure (any time a character imbibes or applies a drug with an addiction rating), the character must succeed on a Fortitude save or become addicted. Instead of having an incubation period as a disease does, a drug has a satiation period, which is the length of time a single dose remains effective in a character’s system. Addiction, if not satisfied by further doses of the drug, proceeds like a disease—the character takes ability damage each day unless he succeeds on a Fortitude save.

Addiction Rating

Each drug is rated according to its addictive potential, from lowest (negligible) to highest (extreme). Sometimes, an individual’s long-term addiction raises a drug’s addiction rating for that individual. Drugs with a negligible rating are not subject to this change. Stronger drugs increase their addiction rating by one step for every two full months a character remains addicted to the drug. A character who recovers from an addiction and later becomes addicted again to the same drug does so at the addiction rating the drug had just prior to his earlier recovery.


Each time a user takes a drug to which he is addicted, he is satiated and staves off withdrawal symptoms for the period of time indicated on the table. Whenever the satiation period expires before the user takes another dose, the DC of the Fortitude save to resist damage (see below) increases by 5. The dose that causes a character to becomes addicted counts for the purpose of tracking the satiation period.


An addicted user who is not satiated takes the indicated amount of ability damage each day unless the character succeeds on a Fortitude saving throw.


If a character makes two successful saving throws in a row, he has fought off his addiction and recovered, and takes no more damage from withdrawal symptoms.

A lesser restoration or restoration spell might negate some or all of the ability damage caused by an addiction, but the next day the victim may take more ability damage if he continues to fail his Fortitude saves. Remove disease immediately causes a user to recover from an addiction, but it does not heal ability damage. Greater restoration or heal causes recovery and restores all ability damage from the addiction.

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 charac ter 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.

Mental Disorders

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.

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.


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.


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.


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.


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—the lists provided below cover merely some of the more common phobias that might affect d20 characters.


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 following lists of phobias for ideas on what sorts of disorders could manifest as manias.

Real-World Phobias

The following list provides examples of phobias from the real world that lend themselves to inclusion in a d20 campaign.

Certain real-world phobias can easily be broadened to include monstrous creatures and specific magic effects in a fantasy environment. For example, ophidiophobia (fear of snakes) could be extended to include medusae and other snakelike creatures, or ichthyophobia (fear of fish) could be extended to include aquatic creatures with fishlike qualities, such as the locathah and the sahuagin.

Phobia Fear of…
Acrophobia heights (formerly known as vertigo)
Aerophobia wind
Agoraphobia open places
Ailurophobia cats
Androphobia men (males)
Astrophobia stars
Autophobia being alone
Bacteriophobia bacteria (“germs”)
Ballistophobia bullets
Bathophobia deep submerged places
Bibliophobia books
Blennophobia slime
Brontophobia thunder
Cenophobia empty rooms
Chionophobia snow
Claustrophobia enclosed spaces
Demophobia crowds
Dendrophobia trees
Entomophobia insects
Equinophobia horses
Gephyrdrophobia crossing bridges
Gynephobia women (females)
Hamartophobia sinning or making an error
Haphephobia being touched
Heliophobia sunlight or the sun
Hematophobia blood or bleeding
Hydrophobia water
Hypnophobia sleep
Iatrophobia doctors (healers)
Ichthyophobia fish
Maniaphobia going insane
Monophobia being alone
Musophobia mice (and rats)
Necrophobia dead things
Nyctophobia night or nightfall
Odontophobia teeth
Onomatophobia a certain name, word, or phrase
Ophidiophobia snakes
Ornithophobia birds
Pediphobia children
Phagophobia eating
Phonophobia noise, including one’s own voice
Pyrophobia fire
Scotophobia darkness
Spectrophobia mirrors
Taphephobia being buried alive
Teratophobia monsters
Thalassophobia the sea
Tomophobia surgery
Uranophobia the heavens (“the horrible gaping sky!”)
Vermiphobia worms
Xenophobia foreigners or strangers
Zoophobia animals
Fantastic Phobias

With some imagination and a little knowledge about how “phobia” terms are formed (most come from ancient Greek words), it’s possible to come up with a list of phobias tailored to a fantasy setting. The following list is provided as a starting point.

Phobia Fear of…
Arcuophobia bows
Aurophobia gold
Aberraphobia aberrations and creatures with tentacles
Bogyphobia demons and goblins
Demonophobia demons
Dracophobia dragons
Confodiophobia being stabbed
Faephobia fey
Gigaphobia giants and Large or larger creatures
Hadephobia hell
Hagiophobia saints and holy relics
Hierophobia priests and sacred items
Incantophobia enchantment and mind control
Iophobia poison
Manaphobia magic
Materiophobia constructs
Myxophobia oozes
Naturaphobia nature and druids
Planarphobia outsiders and extraplanar creatures
Plantaphobia plants and plant creatures
Phantasmaphobia specters or ghosts
Pneumatophobia incorporeal creatures
Uranophobia heaven (esp. divine magic)

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.


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.


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 Charismabased 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.


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


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


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


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


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


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


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


Procrastinator, stubborn, intentionally forgetful, deliberately inefficient. Sabotages own performance on a regular basis.


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


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.


Impaired cognitive function, emotional detachment.


Inappropriate behavior, shallow emotional responses, delusions, hallucinations.


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


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.


“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 Fog

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.


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


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.


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.


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.


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 Sample Drugs, earlier in this section).

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.

A Psychiatric Glossary

The following words are defined in terms of a real-world understanding of insanity; some of them (illusion, for example) have different meanings in a d20 game context. As with all aspects of the Sanity variant, GMs need to determine how each race and culture within the campaign world views insanity and how capable each race and culture is of treating mental disorders in order to know which of these words might come into play.


The external expression of a patient’s mood (sadness, anger, joy, fear). May be inconsistent with patient’s mood, depending on the disorder.


Loss or decrease of appetite.


Various strong motor anomalies, for instance catatonic stupor (slowed activity to the point of immobilization); ceraflexibilitas (the victim can be molded into strange postures that are maintained), and catatonic excitement (agitated, purposeless movements).


The need to perform certain actions repetitively, including various personal rituals, dipsomania, kleptomania, nymphomania, satyriasis, trichotillomania (pulling out hair), and so on.


A reversible syndrome of bewilderment, restlessness, confusion, and disorientation, associated with fear and hallucinations, all caused by some underlying medical condition.


A firmly fixed false belief, one not based in real ity. It can be bizarre, as in schizophrenia, or systematized, as in delusional disorders.


A loss of cognitive function, often first manifesting in memory loss.


A subjective feeling of being unreal, or unfamiliar to self.


A subjective feeling that the environment is strange or unreal; for instance, feeling the world to be a stage or a two-dimensional painting.


Confusion over one’s sense of self and identity.


The feeling that insects are crawling all over one’s body, a tactile hallucination caused by cocaine and delirium tremens.


A perception of a sensory stimulus in the absence of sensory stimuli; for instance, seeing or hearing some one who isn’t there.


The misperception of a sensory stimulus; for instance, seeing the rustling branches of a tree as tentacles.


Copious, coherent, logical speech.


A mood characterized by elation and increased activity.


A pervasive feeling that is experienced internally.


Symptoms of depression, anxiety, or the like arising from stress. A neurosis is less severe than a psychosis. A neurotic character may still be able to function; a psychotic one generally cannot.


An idea or thought that constantly intrudes into one’s consciousness.


Persistent, consistent, plausible, and ingenious delusions of persecution or jealousy. New information always seems to support the increasing threat of some great conspiracy. Paranoia is more a symptom than a disorder, because it can appear in schizophrenia, mania, and so on


Severe mental illness in which the character experiences thoughts and perceptions that are out of touch with reality. A psychosis is more severe than a neurosis.




Abnormal drowsiness.


Sensation caused by another sensation; for instance, seeing sound.


Involuntary spasmodic motor movement.

Trailing Phenomenon

Perceptual abnormality associated with hallucinogens in which moving objects are seen in a series of discrete discontinuous images.


Focused attention and altered consciousness, usually seen in hypnosis, dissociative disorders, and ecstatic religious experiences.