5e: Madness and Sanity Scores

Written by Leonardo Andrade

Leonardo is a writer/narrative designer. He spends most of his time crafting stories or immersed in them. Currently, he partakes in several D&D 5E campaigns and likes messing around with other systems such as Heart, Spire and Rats in The Walls. Here's his portfolio.

Here’s one way to do Madness in D&D 5e: “To drown in memories is a dreadful fate. Too many lifetimes rush through your mind with no regard for the structure of you, spilling forth into the ether. Well, most of them. Some come apart, and their remnants fill the cracks of you once the flood has gone. Some things are lost; some are gained. By the end of it, it’s hard to keep track of which ‘you’ was born in this body. It hurts to try.” 

D&D Madness isn’t about accurately portraying mental illness. It’s about a fantastical shattering of the mind by the uncanny, weird, or magical. This manifests as short or long-term Madness effects or more-or-less permanent character flaws. There are even variant rules concerning a Sanity Score.

Naturally, that’s not all it needs to be. I’ll say right now that, with a little work, you can come up with more interesting Madness tables than the ones provided by the Dungeon Master’s Guide (DMG, pgs 259-260) and elevate Madness‘ impact on the game without being mean to your players.

But first, let’s go over the basics.

5e: The Basics of Madness

There are many ways to go mad in this game. It can come as:

  • an environmental hazard when traveling the multiverse, like the Psychic Winds of the Astral Plane (DMG, pg 47); 
  • the side effect (or intended effect!) of a spell;
  • the effect of poison, disease
  • or torture (not to be added to a game lightly, session zero applies);
  • the result of being exposed to the eldritch incomprehensible or some mental overload (like drowning in memories).

You can even give Madness-inducing properties or abilities to enemies. It goes well with psychic damage

Regardless of the source, D&D 5e Madness comes in three flavors:

  • Short-term Madness: lasts for 10 minutes 
  • Long-term Madness: lasts for 1d10 x 10 hours
  • Indefinite Madness: lasts until cured 

Both short and long-term Madness tend to have clear negative mechanical effects. Indefinite Madness manifests as largely roleplay-dependant character flaws. There are official tables of effects for all of these in the DMG (pgs 259-260) and, since they are part of the 5e SRD (aka Open License), we reproduce them here for your convenience:

Short-Term Madness Effects

d100Effect (lasts 1d10 minutes)
01–20The character retreats into his or her mind and becomes Paralyzed. The effect ends if the character takes any damage.
21–30The character becomes Incapacitated and spends the duration screaming, laughing, or weeping.
31–40The character becomes Frightened and must use his or her action and movement each round to flee from the source of the fear.
41–50The character begins babbling and is incapable of normal speech or spellcasting.
51–60The character must use his or her action each round to attack the nearest creature.
61–70The character experiences vivid hallucinations and has disadvantage on ability checks.
71–75The character does whatever anyone tells him or her to do that isn’t obviously self-­ destructive.
76–80The character experiences an overpowering urge to eat something strange such as dirt, slime, or offal.
81–90The character is Stunned.
91–100The character falls Unconscious.

Long-Term Madness Effects

d100Effect (lasts 1d10 × 10 hours)
01–10The character feels compelled to repeat a specific activity over and over, such as washing hands, touching things, praying, or counting coins.
11–20The character experiences vivid hallucinations and has disadvantage on ability checks.
21–30The character suffers extreme paranoia. The character has disadvantage on Wisdom and Charisma checks.
31–40The character regards something (usually the source of madness) with intense revulsion as if affected by the antipathy effect of the Antipathy/Sympathy spell.
41–45The character experiences a powerful delusion. Choose a potion. The character imagines that he or she is under its effects.
46–55The character becomes attached to a “lucky charm,” such as a person or an object, and has disadvantage on Attack rolls, ability checks, and saving throws while more than 30 feet from it.
56–65The character is Blinded (25%) or Deafened (75%).
66–75The character experiences uncontrollable tremors or tics, which impose disadvantage on attack rolls, ability checks, and saving throws that involve Strength or Dexterity.
76–85The character suffers from partial amnesia. The character knows who he or she is and retains racial traits and class features but doesn’t recognize other people or remember anything that happened before the madness took effect.
86–90Whenever the character takes damage, he or she must succeed on a DC 15 Wisdom saving throw or be affected as though he or she failed a saving throw against the Confusion spell. The confusion effect lasts for 1 minute.
91–95The character loses the ability to speak.
96–100The character falls unconscious. No amount of jostling or damage can wake the character.

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Indefinite Madness Effects

d100Flaw (lasts until cured)
01–15“Being drunk keeps me sane.”
16 – 25“I keep whatever I find.”
26–30“I try to become more like someone else I know—adopting his or her style of dress, mannerisms, and name.”
31–35“I must bend the truth, exaggerate, or outright lie to be interesting to other people.”
36–45“Achieving my goal is the only thing of interest to me, and I’ll ignore everything else to pursue it.”
46–50“I find it hard to care about anything that goes on around me.”
51–55“I don’t like the way people judge me all the time.”
56–70“I am the smartest, wisest, strongest, fastest, and most beautiful person I know.”
71–80“I am convinced that powerful enemies are hunting me, and their agents are everywhere I go. I am sure they’re watching me all the time.”
81–85“There’s only one person I can trust. And only I can see this special friend.”
86–95“I can’t take anything seriously. The more serious the situation, the funnier I find it.”
96–100“I’ve discovered that I really like killing people.”

I encourage homebrewing to match the Madness to the character or make it fit the narrative at hand. More flavorful that way. Here are a couple Madness effects from our very own Weeping Walls adventure module (also found in our Shop):

  • “The character doesn’t feel safe alone in a room and will panic unless they have a party member visible within 10 ft at all times. Panic can mean bad decisions, freezing in place, trying to flee, and so on.”
  • “Until the end of the next combat encounter, the character becomes hypervigilant of their surroundings in anticipation of an attack and has disadvantage on ability checks that narrow their focus (such as thieves’ tools or Investigation). They also can’t maintain concentration on spells. They do, however, have advantage on initiative rolls. After the effect is over, they gain a level of Exhaustion.”

Short and long-term Madness effects can be temporarily suppressed with Calm Emotions and cured by Lesser Restoration and above. This makes Madness unthreatening in most standard campaigns. Even in a low-magic one. To give Madness some bite, curing it should take a lot more than a 2nd level spell slot.

Indefinite Madness takes a Greater Restoration or above to cure. This is a 5th-level spell with a 100 gp cost to cast.

If you want Madness to be a major element of your campaign, consider making the following adjustments:

  • Calm Emotions helps only with Madness effects that induce intense emotions; it doesn’t break someone out of a catatonic state or similar.
  • Lesser Restoration only cures short-term Madness
  • Greater Restoration at 5th-level can cure long and short-term Madness.
  • Curing Indefinite Madness can be done with Greater Restoration, but the caster must beat a very hard to nearly impossible check (depending on the Madness‘ origin) with their spellcasting modifier. Upcasting adds 50 gp to the material component cost and gives a +2 bonus to the check, per spell slot level above 5th that is spent.
    • The same can be accomplished by casting Wish with no checks required.

Conversely, you may implement a Sanity score.

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5e: Variant Sanity Rules

Consider using the Sanity score if your campaign revolves around entities of an utterly alien and unspeakable nature, such as Great Cthulhu, whose powers and minions can shatter a character’s mind.” (DMG, pg 265)

A Sanity score is an ability score like the others. In many ways, it’s Constitution of the mind; mental hardiness. The ability to withstand unnatural stress and supernatural threats to one’s consciousness or to overexert oneself. 

The DMG provides examples of Sanity checks, and they’re mainly substitutions of checks one might do with Intelligence, Wisdom, or Charisma without the threat of Madness. Deciphering a madman’s scrawls without falling prey to the same pattern that locked them into the insanity spiral, snapping out of a delusion, etc.

Sanity saving throws are more likely than Sanity checks. You may require one for a player to remain steadfast upon touching minds with an aberrant being or to avoid a Madness effect if they take a lot of psychic damage in one go. 

A failed Sanity check will typically result in a short or long-term Madness effect, but you can do other things with it, too. For instance, it could trap them in an illusion. Or homebrew a monster that eats Sanity like an intellect devourer eats Intelligence.

Whenever a character suffers from long-term or indefinite Madness, their Sanity score drops by 1. Greater Restoration can restore Sanity lost in such a way. One may use ability score improvements to increase one’s Sanity score, too.

The rules don’t say what happens when a character’s Sanity reaches zero. I’d say that, unless their Sanity is brought back up within a day, they become a mad NPC or go catatonic; the only way to bring them back is with a Wish or divine intervention.

But how do you determine the ability scores at 1st level with the addition of Sanity

  • If you use the standard array, add 11  to it.
  • If it’s point buy, add 3 points. 
  • If you roll for ability scores, roll for Sanity, like any other ability.


Now that the doors of your perception have been opened to the possibilities of Madness in D&D 5e, let’s take a stroll through this alien realm of gameplay to review the key takeaways:

  • 5e Madness comes as short (10 minutes) or long-term (1d10 x 10 hours) Madness effects or more-or-less permanent character flaws that last until cured.
  • Homebrewing Madness effects is fun and makes it more interesting to players. 
  • Calm Emotions to temporarily suppress Madness.
  • Lesser or Greater Restoration to cure it.
  • Because of how easy it is to cure, Madness is less scary than it should be. You can homebrew rules to make it nastier.
  • There are variant rules for Sanity as an ability score (DMG pg 265). It’s essentially the mind’s Constitution.

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