If undergoing counseling, once per month the analyst makes a psychoanalysis check. On a success, the counseled gains 1d3 sanity.

If being medicated, the prescribing doctor makes a psychology and medicine check. If successful, the medicated can ignore half (rounded down) of their missing sanity.

From the rules, page 168-169:

Losing Sanity:

Failing a Sanity roll always causes the investigator to lose self-control for a moment, at which point the keeper should choose an involuntary action for the investigator.

For example:
Jump in fright—causing the investigator to drop something (spectacles, flashlight, gun, book, etc.)
Cry out in terror—drawing attention, saying something inappropriate.
Involuntary movement—swerving the steering wheel dangerously to one side, throwing up one’s hands in horror, cringing.
Involuntary combat action—if a Sanity roll is failed during a combat round, the investigator’s action for that round may be dictated by the Keeper; for example, lashing out with a fist, squeezing a trigger, taking shelter behind someone else.
Freeze—stare disbelievingly for a moment but take no action.

A fumbled Sanity roll results in the character losing the maximum Sanity points for that particular situation or encounter.
Losing more than a few Sanity points at one time may cause an investigator to go insane, as described later. When encountering one ghoul, the Sanity point loss is 0/1D6. It is the same when encountering multiple ghouls; the sanity effect is for the encounter rather than each ghoul seen.

Temporary Insanity

If an investigator loses 5 or more Sanity points as the result of one Sanity roll, sufficient emotional trauma has been suffered that the Keeper must test the investigator’s sanity.
The Keeper asks for an Intelligence (INT) roll. If the roll is failed, the investigator has repressed the memory (a trick the mind uses to protect itself), and does not become insane. Perversely, if the INT roll succeeds, the investigator recognizes the full significance of what has been seen or experienced and goes temporarily insane. The effects of temporary insanity begin immediately and last for 1D10 hours.

Indefinite Insanity
On losing a fifth or more of current Sanity points in one game “day,” the investigator becomes indefinitely insane. No investigator is simply able to shrug off this amount of sanity drain. A “day” in this instance is defined by the Keeper, usually lasting until the investigator reaches a place of safety in which they can rest and recover their wits. Depending on the situation, it may mean surviving until dawn, sitting down for a nice cup of tea, or having a good night’s sleep. Indefinite insanity lasts until the character is cured or recovers.

The Effects of Insanity
Both temporary and indefinite insanity take the investigator through two distinct phases of insanity. First, the investigator experiences a short bout of madness (phase one). This is then followed by a longer period of underlying insanity (phase two), which lasts until the investigator has fully recovered (hours in the case of temporary insanity, months in the case of indefinite insanity).

Insanity Phase 1: A Bout of Madness

Also known as “the red mist,” “frenzy,” “freak out,” and “panic attack.” On becoming insane, the investigator experiences a bout of madness. While experiencing a bout of madness, the investigator loses all self-control. In game terms this means that control of the investigator is handed from the player to the Keeper (for a short amount of real-world time). It is up to the Keeper whether this control takes the form of dictating specific actions or if it means giving the player guidelines on how to play out the madness for however long it may last. On the upside, the investigator cannot lose further Sanity points while experiencing a bout of madness. The mind is completely unhinged at this point and any subsequent horrors are either forgotten or later believed to be a manifestation of the madness. This protection is limited—the bout of madness lasts 1D10 combat rounds (real time) if being played out, but may be longer, in which case the bout is summarized by the Keeper.

Each time an investigator suffers a bout of madness, the Keeper may amend one of the investigator’s backstory entries or add a new one. These alterations serve two purposes. The first is to reflect the investigator’s descent into madness by adding irrational entries or corrupting existing ones. Second, entries can be added or altered to reflect events in the story and thus tie the investigator into the plot more strongly. The player and Keeper should work together to add or revise backstory entries appropriately.

Personal Description: Suitable entries might include “Wild-eyed,” “Thousand-yard stare,” “World-weary,” or “No longer cares for their own appearance”.

Ideology/Beliefs: A balanced entry such as “religious” might be changed to something more extreme or deranged, such as “Unbelievers must be converted or made to suffer”. Alternatively, a new entry that is appropriate to the situation might be made, such as “Obsessed with defeating the Cthulhu cult”.

Significant People: A new name might be added together with a reason for its inclusion. For example, “Can’t rest until Delbert Smith is in his grave,” or “Robin Poole is the incarnation of Ganesh.”

Meaningful Locations: The present location might take on great significance, or the investigator might become fixated on reaching another location for either rational or irrational reasons. The former might be the cult temple in the jungle; the latter might be an overpowering desire to visit Graceland.

Treasured Possessions: It is easy to lose possessions while one’s mind is disrupted by insanity. Any possessions might be erased or noted as lost. A new possession might be acquired and given great significance.

Traits: A trait might be erased or altered to something more suitable; for example: “bully,” “drug addict,” “easily distracted,” “talks too loudly,” “lack of inhibitions.”

Injuries & Scars: These are more usually altered as a result of major wounds.

Phobias and Manias: These may result from rolls during the bout of madness.

Arcane Tomes, Spells and Artifacts: Such items might be lost or destroyed in a fit of pique. The investigator might involuntarily cast any spells that they know, activate artifacts, or study a tome
that they had previously shunned.

Encounters with Strange Entities: Encounters with a monster or deities should be recorded here regardless of whether insanity results or not. This also provides a good place to record the amount of Sanity points lost to a particular type of entity.

Insanity Phase 2: Underlying Insanity

Once the initial bout of madness is over, the investigator enters a lower-level state of underlying insanity. Control of the investigator is placed firmly in the hands of the player, who may freely choose how to roleplay being insane. While the player is not compelled to do so, aspects of the initial bout of madness might be reincorporated for the duration of the underlying insanity. While in the fragile state of underlying insanity (after the initial bout of madness has passed) any further loss of Sanity points (even a single point) will result in another bout of madness. This mental fragility remains for the full duration of the insanity—1D10 hours in the case of temporary insanity—and probably for the duration of the scenario or chapter of the campaign in the case of indefinite insanity.

It is important to note that the investigator, while insane, may act completely rationally and normally, only outwardly presenting their insanity during bouts of madness.

Insanity Side-Effects 2: Delusions and Reality Checks

While not in control of the investigator’s actions, the Keeper is free to present an investigator suffering underlying insanity with delusional sensory information at any time. The only way for the player to be sure of what his or her insane investigator is seeing, hearing, touching, feeling or smelling is to make a “Reality Check”.

Delusions have greater impact when they have some relevance to the investigator. A great way to do this is to refer to the investigator’s backstory and use some aspect as inspiration for delusions. An investigator’s late spouse calling on the telephone is much more engaging than random delusions.

Delusions can also make great consequences when a player of an investigator suffering underlying insanity fails a Pushed skill roll.

Reality Check Rolls

While reality checks are only usually called for on behalf of insane investigators, a player might call for one if they wish to “see through” what they believe to be a hallucination or illusion. To perform a reality check, the player makes a Sanity roll:

Failure: lose 1 Sanity point. This will immediately induce a bout of madness if the investigator is suffering underlying insanity. Any delusions are not dispelled.

Success: the investigator sees through any delusions, and the Keeper must describe what the investigator genuinely perceives.

On making a successful reality check roll, the investigator should see things as they really are and will be resistant to delusions until losing further Sanity points (thus preventing the Keeper from constantly throwing delusions at a player).

Successful use of the Psychoanalysis skill will allow an insane investigator to see a delusion for what it is.

Recovery from Indefinite Insanity

After each month of treatment of an indefinitely insane character, safe from further trauma, the player makes a dice roll. Two sorts of care might help to get the character to this point: private care or institutionalization. In choosing, the Keeper and player should consider the character’s resources, friends and relatives, and past behavior.

Private Care

The best care available is at home or in some friendly place where nursing can be tender, considerate, and where there are no distractions (such as other patients). Analysis and/or psychiatric medications may be available.

To determine the success of treatment with private/home care, roll 1D100:

A result of 01–95 is a success: add 1D3 Sanity points for psychiatric medications or psychoanalysis. This is followed by a Sanity roll for the investigator; if the roll is successful, the investigator is cured of their insanity; if the roll is unsuccessful then a further Sanity roll may be attempted in one month’s time.

If the result is 96–100: the character rebels against taking the drugs or therapy. 1D6 Sanity points are lost and no further progress can be made during the next game month.

Increasing Current Sanity Points

In addition to the care listed above, there are four ways to raise an investigator’s current Sanity points.

1. Keeper award: at the end of a successful scenario or campaign chapter, Keepers may specify dice rolls to increase investigators’ current Sanity points. Keeper award rolls are the same for all participants, but are rolled individually by players. Such rewards should be proportional to the danger the group faced. However, if the investigators were cowardly, brutal, or murderous, the Keeper may opt to reduce or remove the reward, especially if they wish to enforce a moral agenda.

2. Increasing a Skill to 90%: award 2D6 Sanity points when a character increases a skill to 90%. This reward represents the discipline and self-esteem gained in mastering a skill.

3. Psychotherapy: intensive psychoanalysis can return Sanity points to an investigator patient. Make a 1D100 roll against the analyst or doctor’s Psychoanalysis skill once per month. If the roll succeeds, the patient gains 1D3 Sanity points. If the roll fails, add no points. If the roll is fumbled then the patient loses 1D6 Sanity points, and treatment by that analyst concludes—there has been some sort of serious incident or dramatic setback in the therapy, and the relationship between patient and therapist has broken down beyond saving.

In the game, psychoanalysis alone does not speed recovery from insanity; however, it can strengthen the investigator by increasing Sanity points, providing a larger reserve for the active days to come. Recovery is independent of Sanity points. The use of psychoanalysis is different in the game world than in the real world. In the real world, psychoanalysis will not work against the symptoms of schizophrenia, psychotic disorders, bipolar disorders (manic depression) or severe depression. Psychoanalysis is the game’s equivalent of mental first aid and is a world removed from real-life medical care for mental illness.

While in game terms, temporary and indefinite insanity can be cured, permanent insanity is impervious to psychoanalysis. Participation is impossible when the investigator’s mind is in such disarray.

Therapy can also be used to remove a phobia or mania. At the end of a month the analyst rolls for success in the same manner as detailed above. If successful, the investigator then makes a Sanity roll. If both rolls are successful the phobia or mania is cured and erased from the investigator’s backstory. This benefit replaces the Sanity point gain and no such points are awarded. Failure of either of the rolls bestows no benefit. Fumbling either of the rolls results in a loss of 1D6 Sanity points (as above).

4. Self-help: an investigator may choose to spend time with one entry listed in their backstory which could act as a form of psychological support; clearly this does not include phobias, manias, wounds or anything to do with the Cthulhu Mythos. This may be done during downtime between adventures or during the investigator development phase.

The player should go into some detail about what their investigator is doing to seek healing or redemption. The actions should be thematically appropriate to their backstory; perhaps the investigator is going on a religious retreat or a holiday with a loved one. The player then makes a Sanity roll. Keeper and players are encouraged to roleplay the scene to the point where it comes to a head, and then make the Sanity roll, roleplaying the outcome. If the roll is successful, the investigator gains 1D6 Sanity points. If it is unsuccessful, 1 Sanity point is lost, and the Keeper and player should revise that aspect of the investigator’s backstory in some way to reflect the failure. Thus the religious retreat might result in a complete loss of religious faith, or a family holiday might result in separation or divorce.

Each investigator begins the game with one backstory entry that is especially important to them: this is their “key connection”. If the player chooses to use their investigator’s key connection, they are granted a bonus die when making their Sanity roll. In addition to the 1D6 Sanity points gained for a successful Sanity roll, the investigator will recover from any indefinite insanity. If the Sanity roll is failed, that aspect of the investigator’s backstory is revised, and that investigator no longer has a key connection.

In time, the investigator may form a new key connection. During a future investigator development phase, a backstory aspect may be converted into a new key connection if the player successfully uses the “self-help” option to regain Sanity points via that connection. Alternatively, any Sanity roll of 01 (critical success) allows for the immediate nomination of a new key connection to replace the one that was lost.

Note: Current Sanity points can never increase above an investigator’s maximum Sanity (99–Cthulhu Mythos skill).


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