Madness in 5e

Madness is 5e is fairly straight forward. Something could cause the madness, players make Wisdom saves, and those who fail role on a table to see what they get for 10mins, 10 hours,the rest of their life.

Is it rather 2-dimensional? Yes, indeed. But no more than the combat system. And I personally like something with a bit more – Call of Cthulhu light if you will.

I ‘d like Madness to have more effect on the character, their decisions, and specifically, consequences. Lets start with what could cause the madness save.

Causes of Madness


This is simply something causing the target to be afraid. This could in fact be caused by anything that has a fear effect, but having players make a fear save, followed by a madness save is rather disheartening and adding to much.

However, I could see creatures (anything with legendary actions) that causes fear to Instead cause a madness save. Fail and go mad, save and you’re just afraid. Remember there are a lot of powers and spells that negate fear so this isn’t as horrifying as it really should\could be. 


Just being startled could cause a madness check, and have a fairly low DC for say – an ambush in the day. A little higher for an ambush at night. 

I’d also have players make a madness save the first time they encounter something scary. First time seeing lesser undead – madness save. Every time they meet greater undead (greater Vampire, litch, etc.). 

You really think meeting with Strahd is an everyday occurrence?!?  


Detesting something so much it drives someone mad. This I would only incorporate if there is a good character background or a social reason. 

Example. A party meeting with the dreaded Ssú anytime since every humanoid is taught from birth about the dreaded Ssú, therefor it would be a societal detestation. 

Pressure, Stress, and Responsibilities

Characters put into stressful situations, under pressure, and with overwhelming responsibilities should be making madness saves anytime something pushes the envelope. 

Example. Out of the Abyss, the characters are captured and brought into the Underdark, they then must escape, and also take the responsibility of organizing a group of escaped slaves and later, an army. All well never seeing the light of day. In the first part I would have characters make madness saves if someone in the extended group dies, or if there aren’t enough rations for everyone, meaning someones going hungry. If characters opt to go hungry instead of NPC’s I wouldn’t have them roll, but if they sacrifice NPC’s health for their own, they would be making madness saves. 


There are two ways I can see this being used. The first is if the characters are abused, perhaps captured and tortured for information. 

The second, and more likely way this would cause a madness save is if the players abuse an NPC. Also, excessive violence within a situation could cause madness. Want your PC’s to be less murder hobos, make the mental trauma of ending others lives so traumatic that they might want to entertain other solutions. 

Then there is also the witnessing of abuse – by other party members, or perhaps encountering an in-use torture chamber in a dungeon. 

Points of Madness

Now using the above Causes of Madness can mean PC’s are making more madness checks – which could mean they have a few Indefinite Madness’s.

I prefer a 3 strike system. The first time a character gets a ‘Short-Term Madness’ it effects them normally, and the player makes a note of what type of madness. Now if they fail the next two madness save’s, they are effected in the same way. On the 4th fail, they get a ‘Long-Term Madness’, which then note down. The next two failed madness saves and they suffer the same thing. After which they gain an ‘Indefinite Madness’, and the start again at getting perhaps a new ‘Short-Term Madness’.


Clearer causes of madness sets a precedence with players and lets them figure out ways to avoid having to make such checks. They then have expectations and can also use the same rules to their advantage (creating a haunted night ambush).


Rules on D&D5e Madness

Alternative Insanity Ideas

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