The Sights and Sounds of Delirium: Sanity as Narrative and Gameplay

Since the 1990s with the Clock Tower series, games have been interested in examining the use of sanity both as a mechanic and as a plot device. Many horror games have since adopted this Lovecraftian trope in various ways. I would like to take some time in examining the various tropes and approaches studios have used since then for interpreting the loss of sanity, while also postulating where it could go going forward.

In the subtitle I made a distinction between sanity as plot device and as a mechanic. That is because there are games that has the protagonist struggling with sanity that is not influenced by systemic consequence, instead being the result of progressing through the story as a way of building tension, or character development. Since Clock Tower used sanity as a mechanic, I will start from there.

Fear the Dark

Generally, when sanity is used as a mechanic it acts like a secondary health bar that is usually invisible to the player, using diegetic cues to inform the player of its status. Complete depletion of the sanity bar can result directly in death (Call of Cthulhu: Dark Corners of the Earth), or it debilitates player agency through restricting movement, vision or hearing (Clock Tower, Haunted Grounds, Amnesia: The Dark Descent, etc.). Two of the major elements that can drain your sanity are seeing or hearing the monster/enemy that will chase you, or staying in darkness for too long. In Amnesia: The Dark Descent, players are meant to hide to evade the monsters that roam the castle, and they are equipped with tinderboxes to light candles, and a lantern that has a finite (but refillable) amount of oil.

Paranoid, Abusive, Selfish or Irrational?

In the Darkest Dungeon, you send your party into dungeons with a finite number of torches, so tight resource management, and eliminating stress inducing enemies first in a fight are necessary for long term success. An interesting spin in this game is the use of a sanity “test” when a character has reached 100 stress (200 being a heart attack and death). There’s a small chance they can end up being virtuous, which reduces stress buildup and can provide buffs to heroes, but generally will end up indefinitely insane until returned to the Hamlet. These bouts of madness are generally represented in negative character traits that has the afflicted acting out against other party members, skipping their turn altogether or interacting with objects in the dungeon that are detrimental.

A quick note as well to mention the game with possibly the most extreme and meta interpretation of the mechanic, Eternal Darkness: Sanity’s Requiem. In this game your sanity is drained by eyeing the monsters for too long, and is reduced by hacking away at their corpse upon defeat. If your sanity meter got too low however, the game would start to play tricks directly on the player, such as: pretending to delete your save, cutting to a bluescreen, and making it seems like the TV had muted itself accidentally. While it is certainly interesting, the idea of targeting the player instead of the character does pose some interesting questions about immersion and tension.

Scripted Insanity

In Outlast 2, you play an investigative journalist Blake who is doing a feature on a pregnant woman mysteriously found on the side of the road in Northern Arizona. As Blake makes his way through the wilderness, he starts to hear things, and sometimes when he picks up a document or re-watches a grizzly scene he has recorded, refers to a character named Jessica. Throughout the game as well you will suddenly end up in a school, whose clean and quiet atmosphere juxtaposes well with the rest of the game. What the player finds out over time is that these hallucinatory sections are Blake’s catholic school from his youth. You begin to unravel the story behind Jessica, resulting in a tragic self realization for Blake, leaving him completely broken by the end of the game.

Nothing in Outlast 2 is systemic in the way it handles the characters’ sanity. It’s a linear, curated experience where every hallucination or change in scenery is a conscious choice, meant to drive the mystery forward. Other games that follow similar structures are: Condemned: Criminal Origins, Layers of Fear and Blair Witch. With this approach you have much more creative freedom in how these events manifest, as you’re not bound in maintaining a cohesive system that has to account for all the different decisions players can take throughout the game. Sanity can have a personal value for the protagonist and can allow a deeper understanding through the manifestations of their psyche.

The main trade off is that the player is not longer interacting with their sanity in the same way. It is not a resource, and as such the effectiveness is based on emotional investment. From a game to game basis, this means that they run the risk of not communicating the relevancy of an event to their character, or even worse, failing to resonate with players at all.

A Variety of Insanity

There are of course games that have aspects from both approaches. In Amnesia the Dark Descent, while the result of sanity loss always manifests in the same way as you play the game, there will be sections where the game forces you to a crawl, and you begin to hear conversations in your head that provide exposition and insight into your character’s psychology.
Conversely, in Layers of Fear, all of the events you witness provide some insight into the character’s mind, the interactive portion stems from manipulating the environment based on where the player character is facing.

In a nutshell, an effective rendering of sanity in games as both an interactive element and a plot device is important for immersion and fulfillment once the story has concluded. It is crucial for the player to feel complicit in managing their protagonists’ sanity, while also becoming invested in that character’s psychology and story arc. In terms of how this can be handled in the future, games can start taking a look at the actual environments the characters are placed in, and how you can represent low sanity manifestations in a unique way for each setting. Other things to consider are where the player is at in their personal arc and self discovery, the “real” threats that the player faces, and also whether or not you even want a characters’ hallucinations to be a result of their own minds, or an external force that borders on the absurd.

Pathologic: Immersion Beyond Simulation

I’ve tried to be as vague as possible in this post, because I don’t want to give the impression that you can experience Pathologic by reading an analysis (especially not the sort of armchair stuff that I’m offering), but there will be some minor spoilers here. If you care about that kind of stuff, it’s worth going into Pathologic blind. If you don’t care, or if you’ve already played, then read on.

I impulse-bought Pathologic on GOG in 2014, at the start of my glorious return to PC gaming after half a decade of console life. I’d never heard of the game before, but the reviews were gushing and a skim of the description promised an “immersive survival horror RPG” with a Euro-folkpunk vibe, and that was enough for me. At some point shortly after, I fired it up, but the opening scene had no subtitles and the audio was muffled, so I shut it down. It then sat in my library, untouched for two years.

Not Your Dad’s Immersive Survival Horror RPG

I was reading an interview with Randy Smith in which Pathologic’s title was floated as a pioneering immersive sim, which brought it back onto my radar. Somehow I heard that it had received a new “Classic HD” remaster and, thinking that the subtitle issue might have been resolved, I decided to check it out. I’d taken two weeks off for the new year and decided to at least get past that weird opening scene in the theater before writing the whole mess off. The irony was not lost on me when I realized the game is largely unvoiced and is not lacking in text, thus rendering my subtitle judgement moot. But I was in for a bigger surprise than that.

The game absolutely kicked my ass. I was brutally murdered by a mugger on my first night. I  starved to death when the price of food skyrocketed. I died of exhaustion trying to find my way through the labyrinthine streets. I died in my sleep after failing to note that some stat or another was approaching the breaking point before I bedded down.

And yet, beyond all this unyielding death, I was noticing perhaps the most sophisticated and literary narrative I’d ever encountered in a game. I was living the early days of a plague, and the level of nuance and detail in the behavior of the townsfolk at the level of the text was absolutely staggering. I was negotiating the transfer of emergency powers, administrating the construction of a clinic, advising on how best to negotiate a cure. There was a novelesque subtlety to each plot point.

What’s more, this creepy-quaint, magical realist, Euro-folk hamlet was supporting it all at the systemic level. Prices rose as panic buying ensued. Rumor spread about witchcraft as a possible source of the plague, and vigilantes started to spontaneously attack women in the streets. The infection meandered from district to district. The state sent in outside administrators and, eventually, the army. It was grim in a way that cut right to my bones, in a way that I’ve only seen approximated in a handful of games (S.T.A.L.K.E.R. springs to mind). But beyond grim, it felt real.

A Matter of Perspective

Pathologic is not a “traditional” immersive sim. It isn’t an homage to Thief or Deus Ex, it doesn’t feature a million-and-one-ways to get around a locked door, there are no vents to crawl through or physics objects to toss about. And yet, I might call it the finest immersive sim I’ve ever played. I can’t think of another game that has so thoroughly immersed me in a world to the point where I felt it in my gut (and the closest runner up is IPL’s follow-up The Void, so I’d say they’re onto something). But what makes Pathologic different is the way it shifts focus away from interactivity and hinges its design on creating immersion through perspective.

Perspective is at the heart of Pathologic. The game features three playable protagonists, each experiencing the same basic story from their respective viewpoint. The course of each protagonist’s arc is highly distinct, even featuring changes to the gameplay mechanics. As a result, they hold different ideologies, their friends and enemies are different, they talk to different people and get different information with which to form their markedly different opinions. Only by playing through all three can you gain a full picture of what’s going on in this plague-ridden village on the steppe.

Laying the Foundations

To craft these perspectives such that the player seamlessly adopts them, Pathologic deploys every aspect of its design to support its narrative and themes. The art direction and audio create a stage and backdrop against which the tastefully simulated town persists. The basics are all accounted for: villagers walk about, shops operate, every building can be entered (and looted).

Time passes, and it is not the arbitrary day and night cycle of your standard open-world shooter or RPG. You have twelve days to cure the town, and tasks are only available for a single day. If you fuck up and don’t get to something, somebody gets sick.

And layered on top of this are quirky, handcrafted behaviors triggered by plot events. Over the course of the game, mob rule increasingly overtakes the town. Looters and bandits flood the streets, the infected wander around the quarantine zones. The townsfolk turn to superstition and vigilante justice. Eventually the army shows up, maintaining order with rifles and hygiene with  flamethrowers. As the plot spirals into utter despair, the citizens systemically lash out and slaughter each other.

When combined with the story being conveyed through dialogue with NPCs, the systems mesh to provide a social dynamic to the environment. The town becomes a character in its own right, the emergent discord representing the arc of its conflict with the plague and what that conflict represents for the town’s values. The effect is an exceptionally palpable sensation of desperation that permeates Pathologic’s atmosphere, and it places the player in a very specific headspace. And headspace really starts to matter as the motley cast of characters start whispering in your ear.

Everybody’s Talking

Pathologic’s tutorial comes in the form of a short diatribe by a character known as an Executor. It explains the basics of the game, that time passes without regard to you and that missing important events is a very bad thing. Most crucially, however, it makes no bones about telling you that the NPCs will outright lie to your face. What the villagers tell you—and what you choose to believe—will define your perspective.

But Pathologic goes a step further. The quality of the writing is such that, from the sum total of the information conveyed to you in the course of a playthrough, the emergent effect is a strong identification with the outlook of whichever protagonist you are controlling. Even if you know the plot and intellectually disagree with the character’s principles, the dialogue shapes the story such that the player’s perspective settles naturally into that of the controlled hero.

This is not to say that the path is completely authored for a given protagonist. Although the game is quite rigidly linear, there are opportunities to make choices. There are even multiple endings, but the power to choose freely between them involves metagame elements that are best discovered on one’s own.

Credit must also be given again to the depth of the storytelling. Despite the extreme and at times fantastical nature of the story, the things the characters actually do are not just relatable, but intricately detailed. There is a lot of dialogue in the game, and much of it is devoted to the complex motivations of all the characters. Each of the primary NPCs has a vibrant personality and unique mannerisms through which their diverse worldviews are conveyed.

It’s clear that IPL put as much work into the dialogue as Looking Glass put into Thief‘s stealth. It is the foremost method through which the game’s identity is conveyed. The stories of the characters and the town, settled upon the foundation of despondency laid by the simulation, combine to form the meat and potatoes of Pathologic’s philosophy of immersion.

I Will Survive

If the story and systems are the meat and potatoes, then the survival mechanics are the gravy. They saturate the gameplay experience, elevating the desperation to knuckle-whitening levels. Pathologic’s survival stats are way on the far side of unforgiving. Indeed, the fragility of the protagonist is acknowledged in-world, with characters noting that the very air within the village weakens the constitution and tends those who breathe it towards infirmity. 

In tandem with the survival mechanics runs the town’s economy. Prices change depending on what’s happening in the story, and if you’ve not stocked up before a price hike, you’ll be rooting around in the trash for something to barter with. You’ll be trading tchotchkes to little girls for ammo. You might rob or even kill someone just to ensure your own survival. And you will always feel, at best, as though you’re only just scraping by.

It’s a common anecdote in accounts of Pathologic that a struggling player has hawked their gun for food, and that on its own is testament to just how bracing resource management is in this game. Can you name another game where you’d sell your only weapon to keep from starving to death? 

But you learn to live, teeth clenched, Sword of Damocles bearing down. And each and every decision you make matters more as a result. This goes all the way down from high level resource management to simply picking the quickest and safest way to get from point A to point B. Even just crossing the street can be a life or death experience.

The intense pressure of the stat management creates an urgency in which you have no time to detach yourself from the game. You have to remain inside of the character, working constantly to advance lest you fall idle and waste away. With the systems and story cradling you snugly in the perspective of your character, the survival mechanics strap you in.

Being There

And what a ride. The story of Pathologic is not merely rich and detailed, it’s sweeping and epic, emotional and full of intrigue and human drama, horrific and beautiful at the same time.

And it is all these things because of the pains it takes to create a perspective, a mentality that thoroughly shapes your experience of the game world. In this way, Pathologic ensures that you are not simply playing with a simulated sandbox of a world, but that you are fully inside of it, experiencing all of its pressures and demands and victories and moments of respite as viscerally as possible. And in doing so, it gets inside you.

But don’t take my word for it. Check out what Quintin Smith had to say about his experience playing Pathologic in sync with a friend in his excellent writeup:

“I played through the game at the same time as a friend. He chose the Bachelor, and I was the Haruspicus. Because we played at the same rate, we had the chance to discuss developments in the plot each day. […] My favourite was on day 9, some 20 hours into the game, when the same friend started talking about how he couldn’t play on for much longer. He said that if things didn’t resolve themselves soon he’d give up. He was so tired, he said.

The next day my character went to see the Bachelor to discuss some findings, and I found a man overcome with exhaustion. The Bachelor said that if we couldn’t discover the truth about this disease soon he was going to shoot himself rather than let the illness kill him.

This is what Pathologic does. It creates an interesting, desperate situation and brooks no compromise in letting you experience it. And in unflinchingly making you suffer, you identify with these characters you control to the point of becoming them.”

Immersive sims aren’t actually about the stealth or the shooting, the lockpicking or hacking, or even flushing every single toilet in a 3D building. They are about giving the player a tangible presence in a virtual world, and to this end, Pathologic is outstanding.

I finished my first Pathologic playthrough (as the Bachelor) just shy of the end of my vacation four years ago and haven’t stopped thinking about it since. I’ve since completed the other characters as well, and can confidently say that each is utterly integral to the full story. From the moment I first finished it, I knew Pathologic would stand as one of my all time favorite games.