Sanity Rules

Optional
Sanity Rules
©2019 Matthew Corley

Cover art by JL Giles

Illustrations by Matt Corley, Matt Ray, Toby Lancaster

Editing & Layout by Craig Judd

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Appendix C:
Optional Sanity Rules
“If you gaze long enough into an abyss, the abyss will gaze back into you.”
—Nietzsche

T
he sanity and madness rules Sanity Score
presented here are meant to enhance
role-playing, create challenges for the Your character’s Sanity score is equal to her
players, and bring more color to the character. Charisma score plus her Wisdom modifier. The
They are not intended as an inexorable march maximum Sanity score a character can achieve
to retirement and/or death. There are other is 25. The character’s maximum Sanity and her
games for that; and if you have the opportunity current Sanity should be recorded separately.
I highly recommend playing one sometime. You The character’s Sanity can change based on
may be surprised at how fun they can be. Sanity checks. In most cases, the character can
The characters in the 5th edition of the recover lost Sanity through either magic or the
world’s most famous RPG are, above all else, expenditure of downtime days. The character’s
exceptional. They are not regular folks thrust into Sanity score cannot exceed her maximum as
extraordinary circumstances by chance. They are determined by her Charisma and Wisdom scores.
capable of winning virtually any fight, overcoming
epic challenges, and creating miracles. These • Sanity Score = Charisma score plus Wisdom
rules keep that spirit in mind. As always, adjust modifier (Max = 25)
as needed to accommodate your players, your • Your max Sanity score changes as your ability
campaign, and your style of running the game. scores change
• The character should record their current
Sanity and max Sanity
• Your Sanity score uses the same modifier
T he D escent I nto scale as all other ability scores.

M adness Ability Scores & Modifiers

Ability Modifier Ability Modifier
Characters may begin their careers with certain
quirks, eccentricities, or foibles but none can be 1 -5 14–15 +2
said to be insane. That comes later. Each encounter 2–3 -4 16–17 +3
with an undead horde, gargantuan wyrm, or
4–5 -3 18–19 +4
overwhelmingly powerful aberration leaves its
mark upon their psyche. Taken singly their heroic 6–7 -2 20–21 +5
nature allows them to continue to live a life of 8–9 -1 22–23 +6
adventure, fight the good fight, and maintain some
10–11 +0 24–25 +7
semblance of normalcy. The indelible mark on
their psyche, however, can never quite be removed. 12–13 +1

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 A ppendix C: O ptional  S anity R ules

Sanity Checks The player should compare the character’s

current Sanity to their maximum Sanity. If the
To make a Sanity check roll a d20 and apply your Sanity loss brings the character to ½ of her
current (not maximum) Sanity score modifier. max Sanity her madness will be long-term. If
If the roll is equal to or higher than the DC the Sanity loss brings the character to ¼ of
the character succeeds the check and is able to her max Sanity her madness will be indefinite.
maintain her mental coherence. If the roll is less A character whose Sanity reaches zero is
than the DC she fails the check. With a failed irrevocably insane and becomes an NPC.
check she loses a portion of her Sanity and rolls on
the madness table. Any madness that a character Madness
develops is transient unless otherwise noted. A roll
of a natural 1 is considered a fumble and always Unless otherwise noted any madness developed
fails. A specific encounter and/or named NPC/ by a character is transient. If a character fails
creature can only incite a single Sanity check. a Sanity check while afflicted with a transient
madness the subsequent insanity will be short-
Failed Sanity Checks term. If a character is suffering from a short-
term insanity and fails a Sanity check the newly
A failed Sanity check has two results. The first developed psychosis is long-term.
is that the character’s grasp on reality begins A madness will continue to afflict a character
to slip and she loses a portion of her Sanity. until she has had the opportunity to calm
Consequently, the character suffers a (usually) herself, steel her nerves, garner the support of her
transient form of insanity as her mind struggles compatriots, or in extreme cases seek treatment.
to process the situation. If a character must The greater the damage to her intellect the
make more than one Sanity check, each check more time and effort needed to suppress the
is handled independently and the effects are manifestation of her failed Sanity check.
additive. If the character fumbles her Sanity check Transient insanity will continue to affect the
roll, i.e. rolls a natural 1, she automatically fails the character until she has completed the encounter
check and the amount of Sanity lost is doubled. that caused the Sanity check. To quell the transient
insanity the character need only find a quiet place
Losing Sanity and spend a few minutes reassuring herself.
Short-term insanity afflicts the character
After failing a Sanity check the player must roll until she has spent a short rest garnering the
1d4. The result of that roll is the amount of support of her friends, regaining her nerve, and
Sanity that the character loses. rebuilding her mental defenses.
Long-term insanity persists until the
For example, Arkhos has a Charisma of 16 and a character is able to spend downtime to address
Wisdom of 8. His Sanity score is 15 (Charisma score the condition. If you are not using downtime
plus his Wisdom modifier of -1) and his modifier is in your campaign, it is after she has finished the
+2. He has to make a Sanity check upon facing an adventure or quest she’s on. She will need weeks
unspeakable horror. The DC for the check is 18. Arkhos of rest and support to quell the madness that has
rolls a 12, adds his modifier of +2, and has a final result her in its grasp. After that time has elapsed the
of 14. He fails the check. Arkhos rolls a d4 and loses 2 long-term insanity is resolved.
points of Sanity from his interaction with the horror. Indefinite insanity is permanent unless cured.

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 G oing I nsane

intervention. A character with a long-term and/

G oing I nsane or indefinite madness should still be playable and
can offer a great opportunity for role-playing.
“All it takes is ONE BAD DAY to reduce After each long rest the character must make
the sanest man alive to lunacy…Just one bad day.” a Sanity check to see if she is able to temporarily
—Joker suppress the effects of her condition until her
next long rest. If the check fails the character
The acute manifestation of the lunacy exhibited suffers the effects of her psychoses until her next
by the character should be thematically long rest, when she is able to repeat her Sanity
congruous with the situation that caused the check. If the check is successful the psychosis is
initial sanity check. That said, the link between held at bay until the next long rest.
the symptoms and the situation causing the The initial DC for suppressing a long-
behavior may not be immediately obvious. term or indefinite madness is 10*. With each
This is an opportunity for the player and the successful Sanity check it becomes harder to
DM to be creative and develop the character’s suppress her madness and the DC increases by
idiosyncrasies. 1 over the previous check, until the character’s
The tables provide a plethora of options for condition manifests and the process starts over.
the DM and player to explore for characters that
are experiencing transient, short-term, long- For example, Mal’s experiences in the Underdark
term, and/or indefinite insanity. When relevant haunt him daily, or more precisely nightly. His
the DM should roll or choose an entry from the particular form of indefinite madness manifests as
appropriate table below. night terrors. This morning he sets out for his next
adventure and he checks to see if night terrors will
Short-Term/Transient Madness affect him. He rolls a 7 and adds his Sanity modifier
of +4 for a total of 11. He makes his check and is
The acute nature of these manifestations means able to suppress the terrors. The next morning the
the character can quickly shake them off. In the DC is 11 and again he makes the check. By the third
case of transient madness, a few moments out of day the stress of the expedition is beginning to wear
combat is all that’s needed, and for short-term him down. The DC is now 12. He rolls a 6, adds his
insanity the character can resolve the condition modifier and fails his check. During tonight’s long
with a short rest. rest he suffers from night terrors.

Long-Term/Indefinite Madness If a character is unable to suppress their madness

after a long rest it will manifest as a persistent
The effects of long-term madness persist until effect and/or as an acute effect in times of stress.
a character is able to completely recover both In those situations, the character may experience
mentally and physically from adventuring. A an acute attack of lunacy. Stressful encounters
long-term condition ends after the character has include combat situations and may include
had at least a few weeks’ break from the stresses non-combat encounters such as negotiations or
of adventuring. interrogations with NPCs at the DM’s discretion.
The effects of indefinite madness are pervasive
and cannot be cured except through exceptional
intervention such as a wish spell or divine * If a character is suffering from multiple forms of
madness each instance is handled independently.

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 A ppendix C: O ptional  S anity R ules

During a high-stress situation, the PC may her Wisdom modifier to the check. If the
attempt to control themselves for the duration character fails her check she suffers the Acute
of that encounter. This requires a DC 12 effect associated with her madness.
Charisma save, and the character should apply

Transient and Short-Term Psychoses

d100 Disorder Effects
01-05 The character fixates on a mundane The DM chooses an object(s) in the room and the
object within the room and begins to character must use her action to count the objects.
count all instances of it. She cannot do The character can only take reactions while counting.
anything until finished counting the Counting takes 1d4 rounds.
objects.
06-10 The character babbles unintelligibly. The character cannot communicate or cast any spells
Vocalizations are in her native language with vocal components for 1d4 rounds. Perception
and can be heard by any nearby checks against the character have a +2 modifier.
creatures.
11-15 The hairs on the character’s arms The character has a +2 bonus on initiative.
prickle, her heart races, and she break
out into a sweat as a feeling of dread
suffuses her.
16-20 The character is terrified of the object of The character must use her full movement to retreat
her Sanity check. from the object of her terror. She can still take actions
after her movement. The effect lasts one round.
21-25 The character’s mind redirects the terror The character will not willingly interact with the
of the situation to a random object in object that instigated the Sanity check for 1d4 rounds
the area. or until that object attacks her.
26-30 The character loses sight while her mind The character is blinded until the beginning of her
processes the weirdness before her. next turn.
31-35 The character falls prone and curls The character is prone and incapacitated until the
inward upon herself. She makes herself beginning of her next turn.
as small as possible, rocking gently with
her eyes closed.
36-40 A peal of crazed laughter escapes Perception checks against the character have a +2
the character’s lips before she regains modifier. Persuasion checks by the character have a -2
composure. penalty. The effect ends after one round.
41-45 Something inside the character breaks The character makes a melee attack against the nearest
and her vision turns red with rage. creature that is not an ally. If a creature is not within
melee range, the character uses her full movement to
get closer to her target and makes a ranged attack.

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Transient and Short-Term Psychoses

d100 Disorder Effects
46-50 Anything is better than what is before The character cannot tell the difference between what
you. Hallucinations assail the character is real and what is not real until the beginning of
and she cannot tell reality from fantasy. her next turn. While hallucinating the character has
disadvantage on all actions.
51-55 The character’s stomach churns and The character suffers the poisoned condition for the
rumbles as her body reacts to the next 1d4 rounds.
unnatural scene before her.
56-60 The character retreats into her mind The character will not act without outside direction
waiting for someone to give her for the next 1d4 rounds. The character makes all
direction. saves vs charm effects and Charisma based skills at
disadvantage. Allies can use their reaction to give basic
directions to the character while she is affected.
61-65 A pervasive sense of fear penetrates the The character is frightened until the beginning of her
character’s psyche. next turn.
66-70 Nothing makes sense and the character The character is affected by the confusion spell until
has little control over herself. the end of her next turn.
71-75 A part of the character’s body is A leg or arm is paralyzed until the end of the
paralyzed with fear. character’s next turn. Leg – the character’s movement
is halved and she loses half of any AC bonus due to
Dexterity (minimum of 1). Arm – attacks made by the
character are at disadvantage.
76-80 Panic permeates every action and The character has a +2 bonus on initiative and a -2
reaction that the character takes. penalty on saves vs any fear effect.
81-84 The character’s mind refuses to record The Sanity lost from this encounter is reversed and the
the events of the encounter. character has no recollection of the encounter.
85-89 The character’s vocal cords are frozen The character is unable to speak or use any spell with a
and she is unable to make any sound. verbal component for the next 1d4 rounds.
91-94 Clarity and focus pervade the character’s The character has a +1 bonus on all skill and attack
senses. rolls for the next 1d4 rounds
95-98 Muscles tense and the character’s heart The character is hasted for 1d4 rounds. When the
races as everything around her seems to effect ends the character cannot take the move action
slow down. for 1 round as she catches her breath.
99-00 The character’s mind expands to take in The DM provides the player with the following
the madness before her. information about the creature that caused the Sanity
check: CR, resistances, vulnerabilities, and immunities.

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 A ppendix C: O ptional  S anity R ules

Long-Term and Indefinite Psychoses

d100 Disorder Effects
1-3 The character fixates on a Persistent effect: If the object of the character’s compulsion
mundane object and must is present the player has disadvantage on Perception,
count all instances of that object Investigation, and Insight checks until the object has been
when encountered. She cannot counted.
do anything until finished Acute effect: The character must use her action to count the
counting the objects. objects. The character can only make reactions while counting.
Counting takes 1d4 rounds.
4-6 The character has panic attacks Persistent effect: The character has a -2 penalty on initiative
as she is overwhelmed with and on saves vs any fear effect.
feelings of helplessness and loses
all hope.
7-10 The character is terrified of a Acute effect: The character must use her full movement to
creature. retreat from the object of her terror. She can still take actions
after her movement. This effect lasts 1 round.
11-13 The character is terrified of a Acute effect: The character must use her full movement to
mundane object in the area. retreat from the object of her terror. She can still take actions
after her movement. This effect lasts 1 round.
14-15 The character loses sight Acute effect: The character is blinded until the beginning of her
intermittently. next turn.
16-17 The character falls prone and Acute effect: The character is prone and has the incapacitated
curls inward upon herself. condition until the beginning of her next turn.
She makes herself as small as
possible, rocking gently with her
eyes closed.
18-21 A peal of crazed laughter Acute effect: Perception checks against the character have a +2
escapes the character’s lips when modifier. Persuasion checks by the character have a -2 penalty.
confronted with a stressful
situation.
22-26 The character’s instinctual Persistent effect: The character has a -2 penalty on Persuasion/
response to any problem is Deception checks and a +2 bonus on Intimidation checks.
violence. Acute effect: The character makes a melee attack against the
nearest creature that is not an ally. If a creature is not within
melee range, the character uses her full movement to get closer
to her target and then makes a ranged attack.

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 G oing I nsane

Long-Term and Indefinite Psychoses

d100 Disorder Effects
27-30 Hallucinations assail the Persistent effect: The character has a -2 penalty on Perception
character and she cannot easily and Insight checks.
tell reality from fantasy. Acute effect: The character cannot tell the difference between
what is real and what is not real until the beginning of her
next turn. While hallucinating the character has disadvantage
on all actions.
31-33 The character’s stomach churns Acute effect: The character suffers the poisoned condition for
and rumbles as her body reacts the next 1d4 rounds.
to the memories that shattered
her mind.
34-36 The character retreats into her Persistent effect: The character has a -2 penalty to Insight
mind, waiting for someone to checks and to Initiative.
give her direction. Acute effect: The character will not act without outside
direction for the next 1d4 rounds. The character makes
all saves vs charm effects and/or Charisma-based skills at
disadvantage. Allies can use their reaction to give basic
directions to the character while she is affected.
37-40 A pervasive sense of fear Acute effect: The character is frightened until the beginning of
penetrates the character’s psyche. her next turn.
41-42 A part of the character’s body is Acute effect: The character is paralyzed until the beginning of
paralyzed with fear. her next turn.
43-48 The character must complete Persistent effect: After each rest (short or long) the character
her daily ritual before leaving must complete a specific series of mundane tasks prior to
camp. receiving the benefits of the rest. The ritual will take at least
30 minutes to complete. If she is unable to finish the ritual she
doesn’t gain the benefits of the rest.
49-54 The character’s thoughts are Persistent effect: The character has a -1 penalty against fear
filled with anxiety and dread. effects.
55-58 The character is startled by the Persistent effect: The character has a +1 bonus to Initiative
smallest sound and is constantly checks and a -1 penalty against fear effects.
reminded of past traumas.
59-61 The only way the character feels Persistent effect: The character must consume twice as much
better is by eating to the point food or feel the effects of starvation. If this is an indefinite
of excess. madness the character has a 5’ penalty to her movement.

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 A ppendix C: O ptional  S anity R ules

Long-Term and Indefinite Psychoses

d100 Disorder Effects
62-64 The character is obsessive about Persistent effect: The character must make a DC 12 Charisma
cleanliness. save prior to placing herself in a situation that will cause her to
get excessively dirty. If she fails the save she may repeat it again
in 10 minutes.
65-67 The character is obsessed with Persistent effect: The character will not willingly place the
protecting a trinket from any object of her obsession in a situation that could cause it harm.
and all harm. The character can make a DC 12 Charisma save to override
this directive for 10 minutes. If she fails the save she may repeat
it again in 10 minutes.
68-70 The character retreats inward Persistent effect: The character reacts to social situations as a
and regresses to her childhood child would.
personality. Acute effect: The character is frightened of all enemies until the
end of her next turn
71-74 The character’s alternative Persistent effect: The character’s personality changes
personality surfaces. significantly. There are no changes to her skills, abilities, etc…
but her alignment may change and the way she reacts to things
should be different.
75-77 The character sleep walks. Persistent effect: During the character’s next long rest she sleep
walks, possibly getting away from camp completely. Regardless,
the character must make a DC 8 Constitution save or she only
gains the benefits of a short rest.
78-80 The character has horrific Persistent effect: During the character’s next long rest she
dreams and night terrors as screams in terror periodically throughout the night, possibly
she relives the horrors she’s attracting the attention of wandering creatures. If she is not
experienced. woken up and calmed down any characters near her must
make a DC 8 Constitution save to gain the full benefits of a
long rest. On a failure the character only gains the benefits of
a short rest. If the character with night terrors is woken, she is
only able to gain the benefits of a short rest.
81-84 The character has turned to Persistent effect: If the character is not under the effects of
drink and/or drugs as a coping her vice then she has a -1 penalty on all skill checks until
mechanism. she is. The penalty increases to -2 if she goes 3 hours without
indulging, and becomes disadvantage after 6 hours of being
sober.

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 G oing I nsane

Long-Term and Indefinite Psychoses

d100 Disorder Effects
83-85 The character’s madness Persistent effect: The character proselytizes at every opportunity.
manifests as religious zealotry She has a -2 on social skills with members of opposing religious
views.

86-88 The character’s demeanor shifts The player rolls a d2 after it is determined that this madness is
from mania to depression with manifesting. Both effects are persistent.
periods of normalcy. On a 1: The character is manic and prone to taking foolhardy
risks. She’s unable to contain her energy and enthusiasm. She
has a -2 penalty on any skill check that requires patience and/
or fine motor skills. She has a +2 bonus on Persuasion and
Performance checks.
On a 2: The character is depressed today, lost in her thoughts
and some actions are a struggle. She has a -2 penalty on all
Charisma skill checks and a +2 on Dexterity (Stealth) checks if
moving at half speed (or lower).
89-91 The character develops a quirk, The player and the DM work together to develop a unique
habit, or pervasive tic. quirk/tic/habit for the character. The effect is largely for role-
playing but could come into play during times of stress.
92-94 The character seems to be no There are no noticeable effects on the character.
worse for her experiences.
95-98 The character sees danger in Persistent effect: The character has a +2 bonus to Initiative
every shadow and thinks people checks and a -2 penalty to Insight checks. If the character fails
are plotting against her in every an Insight check she believes that the object of the check has a
interaction. nefarious motive and is plotting against her.
98-100 The character is a frenetic and Persistent effect: The character has a +5’ bonus to her
chattering bundle of energy at movement. The character makes any saves/checks for exhaustion
all times. at Disadvantage.

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 A ppendix C: O ptional  S anity R ules

therefore does not need to make a Sanity check. On

W hat I ncites a S anity the third round Gor-Og saves against the spell and
its effects end.
C heck ?
E xamples of S pells T hat C ause a
“I knew who I was this morning, but I’ve S anity C heck
changed a few times since then” • Confusion (4th level, PHB, pg. 224)
—Alice • Contact Other Plane (5th level, PHB, pg. 226)
• Fear (3rd level, PHB, pg. 239)
Exposure to magic, esoteric knowledge, or • Feeblemind (8th level, PHB, pg. 239)
aberrant creatures may force the character to • Magic Jar (6th level, PHB, pg. 257)
question her understanding of the world and • Symbol (7th level, PHB, pg. 280)
can fray her mind. Additionally, situations of
extreme terror, confrontation with one’s own E xamples of S pells that D eal P sychic
mortality, and outside attempts to control your D amage
mind leave marks that may never heal. • Feeblemind (PHB, pg. 239)
• Geas (PHB, pg. 245)
Magic Attacks and Effects • Phantasmal Killer (PHB, pg. 265)
• Vicious Mockery (PHB, pg. 285)
Magic can affect the health of one’s mind in • Weird (PHB, pg. 288)
several ways. Merely casting some spells puts the
caster’s sanity at risk. More commonly, spells Forbidden Knowledge
cause psychic damage by directly attacking the
mind. Illusions and charms pose a risk as they Tomes and codices of unspeakable evil or
target the victim’s persona and perception. A unknowable truths have driven many sages
more insidious danger are spells that induce to lunacy. The histories, spells, and rituals
direct contact between the minds of the caster contained within such eldritch books as
and another creature. As a rule of thumb a Iggwilv’s Demonomicon, the Necronomicon,
spell must be of 3rd level or inflict 25 points and Nameless Cults attack the reader’s mind
of psychic damage in a single attack to cause with each page read and truth learned.
a Sanity check. If a spell deals damage over
multiple rounds each instance of damage is DC = 8 + the level of the highest
handled individually. spell in the tome*

DC = 8 + spell level *If the tome does not contain spells the DC is 12
for a rare item, 14 for very rare, 16 for legendary,
For example, Dexter casts Phantasmal Killer and 18 for an artifact
against Gor-Og. Gor-Og fails his save and takes 31
psychic damage. After the damage is dealt Gor-Og Unspeakable Horrors
must make a Sanity check (DC 12) to see if he loses
Sanity and is affected by transient madness. The Aberrations and fiends by their very nature can
following round Gor-Og fails his save against the crack the protective walls around a character’s
spell again but only takes 18 points of damage, and mind. Creatures of either of these types may

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 W hat I ncites a S anity C heck ?

induce a Sanity check at the DM’s discretion. 13). Immediately upon spying the fiend she must
The sight of a creature whose CR exceeds the make a Sanity check. The DC for the check is 11
character’s level by 3 or more always provokes a [8 + (rakshasa’s CR of 13 – Kairon’s level of 10)].
Sanity check. Kairon’s current Sanity score is 14. She rolls a 10
and adds her Sanity score modifier for a final roll of
DC = 8 + [creature CR – the 12; she succeeds at her Sanity check.
character’s level]
Mind-Numbing Terror
A berrations
• Gibbering Mouther (CR: 2, MM pg. 157) The activation of the hindbrain due to extreme
• Chuul (CR: 4, MM pg. 40) terror often causes an immediate effect on a
• Otyugh (CR: 5, MM pg. 248) character’s psyche. Few things incite that terror
• Cloaker (CR: 8, MM pg. 41) more than the sight of legions of undead razing
• Aboleth (CR: 10, MM pg. 13) everything in their path. An encounter in which
the characters are outnumbered by at least 5 to
F iends 1 induces a Sanity check.
• Lemure (CR: 0, MM pg. 76)
• Dretch (CR: ¼, MM pg. 57) DC = 8 + [Encounter CR* – the
• Imp (CR: 1, MM pg. 76) character’s level]*
• Quasit (CR:1, MM pg. 63)
• Bearded Devil (CR: 3; MM pg. 70) *For a horde of creatures use this table to determine
• Hell Hound (CR: 3, MM pg. 182) the CR of the encounter:
• Nightmare (CR: 3, MM pg. 235)
• Incubus (CR: 4, MM pg. 285) CR of the Creatures in the Horde
• Succubus (CR: 4, MM pg. 285) Number of Creatures Multiplier
• Barbed Devil (CR: 5, MM pg. 70)
• Night Hag (CR: 5, MM pg. 178) 1 x1
• Vrock (CR: 6, MM pg. 64) 2 x1.5
• Chain Devil (CR: 8, MM pg. 72)
3–6 x2
• Hezrou (CR: 8, MM pg. 60)
• Bone Devil (CR: 9, MM pg. 71) 7–10 x2.5
• Glabrezu (CR: 9, MM pg. 58) 11–14 x3
• Horned Devil (CR: 11, MM pg. 74)
15+ x4
• Erinyes (CR: 12, MM pg. 73)
• Nalfeshnee (CR: 13, MM pg. 62)
• Rakshasa (CR: 13, MM pg. 257) For example, Griswald (Rogue, 2nd level)
• Ice Devil (CR: 14, MM pg. 75) encounters a roving pack of 10 ghasts (CR 2). The
• Marilith (CR: 16, MM pg. 61) effective CR of the encounter is 5 (CR x 2.5) and the
• Balor (CR: 19, MM pg. 55) DC of the Sanity check is 11. Griswald must make a
• Pit Fiend (CR: 20, MM pg. 77) Sanity check. He rolls a 4, applies his modifier of +3,
and fails the check. The sight of the ghasts unhinges
For example, Kairon, (Fighter, 10th level) his mind. He loses sanity and must roll on the
comes face to face to with her first rakshasa (CR transient madness table.

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 A ppendix C: O ptional  S anity R ules

The presence of an unholy greater undead has G etting B etter

the same effect. The sight of an undead creature
whose CR exceeds the character’s level by 3 or “She was always trying to hide, the
more provokes a Sanity check. beautiful chaos in her mind.”
— Joker
DC = 8 + [creature CR – the
character’s level]* Recovering Sanity does not cure any madness
that was developed due to Sanity loss. The
The final way in which stark terror may affect underlying conditions resolve automatically
the stability of the character’s mind is if a after the character has taken the necessary time
character fumbles (rolls a natural 1) on a check to come to terms with her experiences or, in the
against a fear effect. If the character’s level case of indefinite madness, has it cured with a
is equal to or greater than the creature that wish or other similar magic.
generated the fear effect the DC is 8.

DC = 8 + [creature CR – the
character’s level]*

Struggle for Dominance

The struggle for dominance between a sentient
item and its owner may damage the wielder’s
mind. If the wielder loses a Conflict between
herself and her item, and the item possesses
her, she should make a Sanity check as the item
overwhelms her mental defenses and forces her
to act as it wishes.

DC = 12 + the item’s Charisma

modifier

Character Death
Any character that fails their 3rd death save and
is subsequently brought back to life through
whatever means are available to her allies loses 1
Sanity point. This point cannot be restored by
any means short of a wish. If this change causes
the character’s Sanity to be ½ or ¼ of her max
Sanity she rolls on the long-term or indefinite
madness table respectively.

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 G etting B etter

Recovering Between Adventures • Charm Person (PHB, pg. 221) — as calm

emotions for the duration of the spell
The character may attempt to recover her • Dominate Beast/Monster/Person (PHB,
newly-lost Sanity between sessions. This attempt pg. 234-235) — as calm emotions for the
at treatment may only be done once, at the end duration of the spell
of the adventure in which the character incurred • Enthrall (PHB, pg. 238) — as calm emotions
the Sanity loss. for the duration of the spell
• The DC is dependent on how much Sanity • Geas (PHB, pg. 245) — as calm emotions for a
was lost in the preceding adventure. single psychosis for the duration of the spell
• DC = 8 + the total Sanity lost • Greater Restoration (PHB, pg. 246) — cure a
• The character should apply her current long-term (or shorter duration) madness
Sanity score modifier to this roll • Heal (PHB, pg. 250) — restore 1d4 Sanity
• Regardless of roll, the character may not or cure a long-term (or shorter duration)
increase her Sanity beyond her maximum madness
Sanity score. • Holy Aura (PHB, pg. 251) — advantage on
• Natural 20: always a success and regains 2d4 all Sanity checks; creatures that have failed
Sanity a Sanity check and are within the radius of
• Success: regains 1d4 Sanity the spell may repeat the check at the end of
• Failure: no change in Sanity their turn, ending the transient/short-term
• Critical Failure: loses 1d2 Sanity madness on a success
• Lesser Restoration (PHB, pg. 255) — allows
For example, Griswald’s encounter with ghasts the character to make an additional save
caused him to lose 3 Sanity points. Now that he has to end the effects of a transient/short-term
survived that harrowing experience and it is behind madness
him, he is able to spend the next month fishing and • Mass Heal (PHB, pg. 258) — as heal
relaxing to recover from the ordeal. After the month • Mass Suggestion (PHB, pg. 258) — as calm
Griswald makes a Sanity check. The DC is 11. He emotions for the duration of the spell
rolls an 11 and adds his Sanity score modifier of +2 • Mind Blank (PHB, pg. 259-260) —
for a 12. He succeeds. He rolls a d4 and recovers 2 automatically succeeds all Sanity checks
Sanity points, bringing his current Sanity up to 16. while the spell is active; the character is also
affected as calm emotions for the duration of
Treating Madness with Spells the spell
• Modify Memory (PHB, pg. 261) — the
A player cannot choose to fail a save against any target’s memories of a specific event causing
of the following spells. Sanity loss can be erased, reversing any Sanity
• Beacon of Hope (PHB, pg. 216) — the loss and/or psychoses that resulted from the
target(s) have advantage on Sanity checks original failed Sanity check
• Bless (PHB, pg. 219) — bonus can be • Suggestion (PHB, pg. 279) — as calm
applied to Sanity checks emotions for the duration of the spell
• Calm Emotions (PHB, pg. 221) — ends the • Wish (PHB, pg. 288-289) — can restore
effects of a transient/short-term madness or 2d4 sanity points or cure any single form of
suppresses long-term/indefinite madness for madness that a character is suffering from, up
the duration of the spell to and including indefinite madness

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 A ppendix C: O ptional  S anity R ules

Optional Feats The combination of faith and inner strength

that clerics and paladins possess allows them
to add their proficiency bonus to any Sanity
R esilient P syche checks.
Choose one ability score, either Charisma or The force of will of monks allows them to
Wisdom. You gain the following benefits: use their Stillness of Mind feature to end a
• Increase the chosen ability score by 1, to a transient/short-term madness. Monks may also
maximum of 20 use this feature to suppress the acute effects of a
• You gain proficiency in Sanity checks long-term/indefinite madness for one encounter.
When a monk gains the Diamond Soul feature
C l ass U pdates she may add her proficiency bonus to Sanity
Some adventuring classes are more resilient to checks.
the mental strains and stresses of encountering Warlocks are able to use the strength of
these potentially Sanity-breaking scenarios. their pact and unique perspective to add their
proficiency modifier to Sanity checks.

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 S anity C heat S heet

S anity C heat S heet

Sanity Checks Causes of Sanity Checks

Roll a d20, apply any Sanity modifiers, and • Magic Attacks & Effects:
compare to the DC of the check. A natural 1 DC = 8 + spell level
always fails. Each encounter/creature can only • Forbidden Knowledge:
incite a single Sanity check. Additional checks in DC = 8 + level of highest spell in the tome
a single encounter could be from psychic attacks/ • Unspeakable Horrors:
damage, character death, struggle for dominance, DC = 8 + (Creature CR – PC’s level)
and/or exposure to forbidden knowledge. • Mind Numbing Terror:
DC = 8 + (Encounter CR – PC’s level)
Failed Sanity Check • Struggle for Dominance:
DC = 12 + item’s Charisma modifier
The character suffers a (usually) transient form • Character Death:
of insanity and loses 1d4 Sanity. If the player Automatic failure and loss of 1 Sanity
rolled a natural 1 on the check, the Sanity loss is
doubled. When your character’s Sanity is at ½ of Getting Better
her maximum the madness is long-term; when it
is ¼ of its maximum the madness is indefinite. Between Sessions: DC = 8 + the total Sanity
lost (note the character should use her current
Duration of Madness Sanity modifier).
• Natural 20: always succeeds (regardless of
Transient is until the end of the encounter, short- DC) and regains 2d4 Sanity
term until the end of a short rest, long-term until • Success: regains 1d4 Sanity
the character takes a break from adventuring, • Failure: no change in Sanity
and indefinite is until cured. • Rolls a natural 1: loses 1d2 Sanity
Short-term Madness: If a character fails Spells: numerous spells are available to prevent,
a Sanity check while afflicted with a transient treat, and/or suppress madness.
madness the subsequent madness will be short-
term. Class-Specific Updates
Long-term/Indefinite Madness: If a
character is suffering from a short-term insanity Paladins, Clerics, and Warlocks are all able to
and fails a Sanity check the newly developed add their proficiency bonus to Sanity checks.
madness is long-term. Long-term and Indefinite Monks may end a transient or short-term
madness may also be a result of decreases in the madness using the Stillness of Mind feature.
character’s Sanity score. Stillness of Mind can also suppress a long-term
Suppressing Long-term/Indefinite or indefinite madness for one encounter. The
madness: After each long rest the character may Diamond Soul Monk feature allows the monk
attempt to suppress the madness (DC = 10 + days to add her proficiency bonus to Sanity checks.
since previous bout) until her next long rest.

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 A ppendix C: O ptional  S anity R ules

OPEN GAME LICENSE V ersion 1.0 a

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System Reference Document 5.1 Copyright 2016, Wizards of the Coast, Inc.; Authors Mike Mearls, Jeremy Crawford, Chris Perkins, Rodney
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Lamp’s Light Sanitarium. Copyright 2019, Saturday Morning Scenarios; Author Matthew Corley.

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