An abundance of horrors can scar a being. Wounds and fatigue can ravage the flesh. Poisons and venoms can putrefy a creature from within. Curses and hexes can assault the body and soul through supernatural means. But of all the horrors a hero might face, few are as debilitating or insidious as those that assault her sanity.

The Pathfinder Roleplaying Game already features many threats that can erode a character’s sanity. The insanity spell can cause a character to act confused until its effect is removed. Insanity mist is an inhaled poison that deals Wisdom damage. The allip, an undead creature created when a soul is lost to madness, features several madnessthemed abilities.

For some games, presenting the weakening of sanity and the onset of madness as assaults on a creature’s Wisdom score or the randomness of the confusion condition might be enough. But running a horror-themed game often necessitates a more robust and nuanced system. In the following system, the mental resilience of a creature is based on the totality of her mental being and mental strengths, rather than her weaknesses, improving her chances to weather and triumph against a vast array of sanity-threatening horrors.

Sanity Score, Edge, and Thresholds

Each creature has a sanity score, along with a sanity edge and a sanity threshold. These values depend on the creature’s current ability scores and ability damage. Increases and penalties to ability scores (even temporary increases and penalties) adjust these numbers. Each discrete instance in which a creature takes 1 or more points of sanity damage is called a sanity attack, regardless of what caused the sanity damage. Since effects that deal sanity damage are always mind-affecting effects, mindless creatures are immune, and do not have a sanity score, sanity edge, or sanity threshold.

Sanity Score: Your sanity score is equal to the sum of your mental ability scores (Charisma, Intelligence, and Wisdom) minus any ability damage taken to those ability scores.

Sanity Threshold: Your sanity threshold is equal to the bonus of your highest mental ability score minus any ability damage to that score (minimum 0). When you experience a sanity attack, if the sanity damage from that attack equals or exceeds your sanity threshold, you gain a madness (see page 182), either lesser or greater depending on the relation of your current sanity damage and your sanity edge (see below). If your sanity threshold is 0, you always suffer a madness upon taking 1 or more points of sanity damage.

Sanity Edge: Your sanity edge is equal to 1/2 your sanity score. When you experience a sanity attack that causes you to gain a madness (see Sanity Threshold above), compare your total amount of sanity damage to your edge to determine the potency of the madness. If your current sanity damage is less than your sanity edge, then you manifest a lesser madness. If your current sanity damage is equal to or greater than your sanity edge, you manifest a greater madness instead. More information on madness, both greater and lesser, can be found on page 182. Furthermore, when you accrue total sanity damage equal to or greater than your edge, any dormant lesser madnesses you have manifest again.

Effects of Sanity Damage

When you experience a potential sanity attack, you must typically succeed at a Will saving throw to shake off or reduce the sanity attack’s damage. Whether this saving throw is successful or not, if the sanity damage from a single sanity attack is equal to or greater than your sanity threshold, you gain a madness (see page 182) with a potency based on the relation between your total sanity damage accrued and your sanity edge (lesser if the total sanity damage is below your sanity edge, greater otherwise). In most cases, GMs should choose a madness that reflects the horror faced or your deep fears and potential mental breaking points rather than rolling on tables. For instance, if you gain a lesser madness due to an encounter with a mummy or some other undead that features a fear effect, it might make sense to choose the phobia madness. If you already suffer from delirium and gain a greater madness, it might make sense for that madness to be increased to schizophrenia. However, when a random madness is appropriate, the GM can generate one by rolling on Table 5–1 (for a lesser madness) or Table 5–2 (for a greater madness).

You are afflicted with a madness until that madness is removed by the methods described in Chapter 5. You may not always manifest the madness, though. If you are afflicted with madness and then are healed of all sanity damage, all of your madnesses become dormant until you accrue further sanity damage. Typically, a dormant madness does not affect you at all, but some madnesses feature an effect that occurs only while that madness is dormant. A lesser madness that becomes dormant does not manifest again until you take sanity damage equal to or greater than your sanity edge. A greater madness stays dormant only as long as your total sanity damage remains at 0. Dormant madnesses, no matter the potency, can be removed only by miracle or wish.

Lastly, if your total sanity damage equals or exceeds your sanity score, you become insane as per insanity (no saving throw) until all your sanity damage is healed and all your madnesses are cured.

While Pathfinder RPG Horror Adventures introduces a number of spells, feats, monsters, or other effects that deal sanity damage, the GM is also encouraged to create her own sanity-damage-dealing effects in her horror game. The table below gives a number of examples of situations that might cause a character to take sanity damage.

Reducing Sanity Damage

Sanity damage can be reduced in a number of ways. The first is with time and rest. For every 7 full days of uninterrupted rest, you can reduce the sanity damage you have taken by amount of equal to your Charisma modifier (minimum 1). Instead of relying on your own strength of personality to reduce the effects of sanity damage, you can seek out a single confidante, mentor, priest, or other advisor. You must meet with that person regularly (at least 8 hours per day) and gain guidance during the 7 days of rest. At the end of the rest period, the ally can attempt a Wisdom or Intelligence check (whichever score is higher) with a DC of 15 if your sanity damage is below your sanity edge or 20 otherwise. If the ally succeeds at this check, you can add the ally’s Wisdom or Intelligence modifier (whichever is higher) to the amount of sanity damage you remove.

Sanity damage can also be reduced with magic. A single casting of lesser restoration reduces sanity damage by 1d2 points up to once per day; restoration reduces sanity damage by 2d4 points up to once per day; and heal reduces the amount of sanity damage by 3d4 points up to once per day.

Greater restoration, psychic surgeryOA, and limited wish reduce your total sanity damage to 0 if your total sanity damage was already below your sanity edge; otherwise, these spells reduce your total sanity damage to 1 point below your sanity edge. Miracle and wish instantly reduce your sanity damage to 0, regardless of whether your total sanity damage was below your sanity edge.

Expanded Sanity Effects dealing sanity damage and the madnesses in Chapter 4 are mind-affecting effects, and as such certain creature types are immune to them. In horror games, the GM may want to make an exception to this, at least in the case of sanity damage and madnesses, allowing undead and even some kinds of plant and construct creatures to feel the effects of insanity. The GM should be careful to determine whether the creature’s immunity to mind-affecting effects compensates for an extremely poor Will save and potentially give a bonus on Will saves against sanity damage to such creatures.

Tenacious Sanity In a particularly horror-themed game, the GM may consider removing some or all of the magical options to reduce sanity damage, relying on rest alone to recover sanity. For the most terror, she could even make sanity damage irrecoverable. In these cases, the GM should consider increasing the characters’ sanity scores and sanity edges to ensure the heroes can make it through enough of the adventure before they snap.

The first time a character encounters a dead body10 1d3 sanity damage0 sanity damage
The first time a character encounters a gruesome scene of death121d6 sanity damage1 sanity damage
The first time a character encounters a horrifying creature*10 + CR of the créatureSanity damage equalt to 1/2 the creature's CRSanity damage equal to 1/4 creature's CR
Each time a character encounters a qlippoth or other creature with a particularly horrific appearance10 + CR of the créature Sanity damage equal to creature's CRSanity damage equalt to 1/2 the creature's CR
Each time a character encounters a Great Old One15 + CR of the creatureanity damage equal to double the creature's CRSanity damage equal to creature's CR
* Horrifying creatures are typically aberrations, evil or chaotic outsiders, and undead. “Each time” could mean the first time for each creature type, or each time a creature encounters a new kind of specific creature of that type (for example, the first time a creature encounters a skeleton and then again the first time the character encounters a wraith), at the GM’s discretion.

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