(EDIT: Apparently WotC has had similar ideas - they have a new Stress mechanic in Van Richten's Guide to Ravenloft that does not work the way I describe it here, but has similar ideas. So... great minds think alike? And let's forget that that phrase has a second half that says "though fools seldom differ." Anyway, I've learned a lot more about the book from Nerd Immersion's stream, including a sort of alternate game mode involving underpowered characters called "Survivors" that lets you amp up the terror by giving players alternate characters who really have to run from a monster instead of standing and fighting it.)
In the DMG, two alternate ability scores are presented as possibilities for hacking the game. Honor is designed for games in which courtly manners and protocol play a big factor. Sanity is meant for psychological horror games.
I tend toward the latter genre, and certainly with Van Richten's Guide to Ravenloft occupying some prime real estate in my mind right now, it's the one I'm eager to talk about.
There are two issues I want to address with Sanity. The first is the potentially problematic application. Working in any sort of genre fiction, some tropes of the past don't look so great today, and I don't really know where, as a culture, we've landed on the use of "madness" and "insanity" as something purely for entertainment versus something that can alienate potential players.
At the risk of sounding "too PC," I think we can nudge the language here to emphasize that this is not meant to antagonize people dealing with mental illness (who, statistically, are way more likely to be the victims of violence than the perpetrators) but instead to dig into the horror of how stress can warp the perception and behavior of anyone in the worst circumstances (which a horror adventure surely seeks to embody).
Darkest Dungeon makes this one of the game's central mechanics, and seems like a fantastic idea to pillage. In Darkest Dungeon, each character has both an HP meter and a Stress meter. Even if a hero in that game comes back from their dungeon delve unscathed physically, the things they see might leave them with various negative status ailments that can seriously hinder their effectiveness in future endeavors.
The other issue is that I think Sanity makes more sense (as you might have guessed) as an additional Hit Point system, rather than a separate ability score. There are many existing effects in D&D that already seem to cover mental fortitude, most often in the form of Wisdom saves to resist effects like fear or charm spells, or even Intelligence checks to successfully identify illusions. Adding Sanity as an ability score would muddy the waters here and require reworking many spells and mechanics to fit it in.
So, the basic proposal is that each creature has a pool of Stress Points - just as getting hit depletes your hit points, so does getting stress reduce your stress points.
Hitting zero stress points would be bad - but not necessarily lethal. I think you could also use similar mechanics to what happens when you reach zero HP - rather than going unconscious, a creature with zero stress points goes into a fugue state and is incapacitated. Restoring just one stress point would bring them out of it, shaking the state off.
Equivalent to Death Saves, a creature in a Fugue State would have to make Breakdown Saving Throws, with the same system of successes and failures. With three Breakdown save failures, the character breaks down. The nature of this breakdown is something I'd have to work on, but this represents a serious crisis. There might be a table to roll on here, but any breakdown is going to be a serious problem for the party. For example, one Breakdown could be "Berserk," in which the character can no longer tell friend from foe and must make attacks against any creature they can see.
While some stress healing (which would likely require new spells) can help with someone in a Fugue state, someone with a Breakdown would likely need some kind of more serious magic, equivalent to resurrection magic.
To calculate a character's Stress Points, I think we'd treat this more or less the same as we do with hit points, except rather than Constitution, we should use one of the mental stats to determine it.
I would argue that between Intelligence, Wisdom, and Charisma, it's Charisma that makes the most sense to me to serve as the mental equivalent of Constitution. Charisma is often seen as just how slick and charming a person is, but its use as a spellcasting stat tends to emphasize that it's about the force of personality and sense of self. While I could buy an argument for Wisdom, I think of Wisdom as being more representative of your awareness of things beyond yourself, and given Wisdom's tendency to be used to avoid psychological attacks, I'd position it more as the mental equivalent of Dexterity. (Intelligence, then, gets to be the equivalent of Strength, which also makes sense to me as Intelligence is kind of about raw knowledge and intellect - the mental equivalent of brute force.)
I think Stress damage would likely come in lower amounts than other kinds of damage, and so I'd say that everyone, regardless of class, has a d4 stress die. At level 1, they'd have SP equal to 4 plus their Charisma modifier, and would either roll it each level or take 3, and then add Cha.
Now, in terms of damage taken:
Here, things get a little tricky. If you wanted to just make all fighting stressful (which is not exactly unrealistic,) we could maybe go with the following: when they take damage, they take one Stress Damage for each die rolled for damage by the monster, plus the modifier it adds. So, if a Frost Giant Skeleton hits them for 3d12+6 slashing damage with their Greataxe, the character would then also take 9 stress damage. While that 9 is probably a lot less than the roughly 25 slashing damage, it might be a much bigger deal to the Fighter with 8 Charisma. If we imagine this hypothetical Fighter is level 8 and has +3 Constitution and -1 Charisma, they'd have (using standard amounts) 76 HP, but they'd only have 17 SP - and so they'd be more worried about having a breakdown than getting knocked out.
On the issue of psychic damage, I'm a bit torn. I think psychic damage is usually coded as being the very kind of stressful, sanity-depleting mind warping that we're representing with stress damage. But it can also just represent inflicted pain, like directly stimulating the target's nervous system and giving it a nasty shock, which might be excruciating, but not necessarily any more mind-shattering than dousing them in acid.
I have three potential ways to handle this. One is to simply treat psychic damage like anything else and have it work identically. The next is to have psychic damage only affect SP, but at its full power (though this makes a spell like Psychic Scream not really make sense anymore). The nastiest approach is to have psychic, intrinsically, deal damage to both HP and SP, both at the full amount. This would make psychic resistance really useful, and would make Mind Blank a very powerful spell (as if it weren't already).
Things do get a bit muddied here. Should all stress damage be classified as psychic damage, given that it's all affecting the psyche? I'm not sure, as I think that, since most (if not all) the stress damage you're taking is derivative of other kind of damage, it's more about your reaction to having been hurt than an assault on your mind. It is stress, after all, and not what psychic damage is always meant to convey, which is a magical assault targeting the mind - in a way, it's you who are damaging yourself in response to what has happened (and by keeping the damage types the same, it makes sense that a Barbarian would be less worried about slashing damage in a rage - they know it doesn't hurt their body as much, and so they don't fear as much for their mind).
Of course, one could argue that this is all unnecessary. In fact, Rage's a great example: does a Barbarian's rage allow them to literally take less damage when they are struck, or does it just give them an emotional tool to push through the pain? HP is an abstraction that includes both physical resilience and integrity but also morale and willpower.
Creating a new value to track makes the game crunchier, and gives characters a new axis for strengths and weaknesses, but it will definitely complicate the game (similar to my earlier idea for hacking out a distinction between dodging attacks and absorbing damage with armor and shields).
This sort of deep hack to the game is the kind of thing that I find fun to think about, but even after five years running D&D 5th Edition, I don't feel confident quite yet in this degree of homebrew. Still, it could be fun to experiment some time down the line if it were easier to wrangle people for one-shots.
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