The Use of Sanity Systems in RPGs

I found these two articles on Twitter, they talk about how mental health status effects are conceptualized in RPGs. I for one am a big fan of Homebrew RPGs and fiddling with stats and gameplay mechanics. I am also a big fan of the Cosmic Horror genre. Lovecraftian horror is a huge inspiration for me. However, Lovecraft was a product of his time and I think his literature as well as rpg settings like “Call of Cthulhu” use some pretty problematic gameplay mechanics as to how mental health is represented.

In Call of Cthulhu per example, you are a “normal” character with a number of sanity points. When encountered with horrors beyond your comprehension you lose said sanity points. After a certain point the character experiences a “Bout of Madness” in which you roll a d10 and you might have your character become violent, manic, paranoid or hysterical (Darkest Dungeon drew from this to make a similar mechanic). There’s a lot to unpack here about why mental health is represented with this sort of mechanic.

I usually play with my friends who have no background in mental health and some of them held certain biases towards the mentally ill. I am the designated DM, and I usually bring themes of mental health into my one-shots (I don’t a have a group committed enough to have an actual campaign) and RPG has become a fun way to sneak conversation about mental illness with my friends without being preachy. I am very grateful for that experience. Usually now my friends opt to make characters that are complex and show signs of mental illness and I collaborate with them to create interesting character arcs of recovery (ironically in a Cosmic Horror setting)

What do you think? What types of rpg settings or rulesets can we produce to incorporate themes of mental health into our gaming experience without resorting to damaging stereotypes?


Vampire: the Masquerade was my first experience with RPGs. In that game, if you play a Malkavian (which I almost always did) you have to establish a “derangement” that you’ll be affected by throughout play. I never thought about it then, although now I think it could be a good way to represent mental illness in a positive way, depending on the storyteller. Now I want to pull out my old books and see what the derangements were.

It’s also a theme in tabletop board gaming. I just played a game of Betrayal at Baldur’s Gate last night, and have played Betrayal at House on the Hill sooooo many times. Sanity is one of the mental stats. The more weird and messed up stuff you encounter, the more likely you’ll have to make a sanity roll, and possibly lose sanity points. It’s a pretty simplistic way of showing how experiences effect our mental health and can stick with us, but effective.

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Is derangement like a specific trait a character has starting from character creation?
Like maybe we could rename it “struggle” or “Recurring issue”?

I have watched soooo many people play Betrayal at House on the Hill on youtube, and I’ve always wanted to play it but I gots no one to play it with (and its kinda expensive) because most of my friends don’t want to because they’ve heard its broken either on the victims side or the traitor. I can’t say that’s not what I’ve seen in the videos. But I just think the concept is so fun, it has a lot of value if merely for a short roleplaying roleplaying experience.

Yeah, it’s a stat you take when you become a vampire of the Malkavian clan. Malkavians were essentially cursed by the first vampire and all of their bloodline end up having bizarre behavior and “madness”. They’ve been my favorite characters to play, because I find they’re more interesting and complicated. I’m sure you could change the name derangement to something less stigmatizing. I think the main reason they used a term like that (which is SO old and outdated) is because vampires take even longer to change their ways and rituals, and that’s a word that was used during Victorian times or older.

Some of the examples of derangements you can take are obsessive/compulsive, multiple personalities, schizophrenia, paranoia, megalomania, bulimia (in this case binging on blood), hysteria, manic-depression, fugue, and sanguinary animism (specific to vampires, they hear the voice of their victims after feeding and believe they’re being flooded by the victims memories). Obviously some of the terms are super old fashioned, just like the vampires. The players handbook goes into detail on each one.

Betrayal is so much fun, and some of the scenarios are broken at times, but we usually manage to make it fair or manage to tweak rules to make gameplay faster. It’s interesting that no one will play with you! In my group of friends…everyone wants to play. Every…single…game night!

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That sounds amazing, I really want to play a World of Darkness setting like Vamp: the Masquerade, but every time I look at the rulebook I just get overwhelmed by the lore. As a DM when I work with a system that has a rich Lore if find it hard to take everything into account. Some have told me to pick and choose the things you are interested in, but their lore is sooo nice I get overwhelmed. I love rpgs that focus on narrative over battle, and this game looks very promising.

Malkvians remind me of Urban Shadows which is an rpg setting that I heard about from the Adventure Zone Podcast. It focuses on a world where you have contacts and you mostly solve problems through your own abilities and political tit-for-tat. It’s a world where humans and the supernatural coexist. They have a system of corruption, and its very interesting how it works. The more your character does things against their general code of ethics or depends much on their primal power (vamps, werewolves, ghosts) they gain corruption. The more corruption you have the more power you have but also the less control the player has over their actions and the more th DM does.

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