Psychiatric illness can be frightening, tragic and insidious. It can be a powerful storytelling tool, and can be an interesting challenge to roleplay as a player.
In fiction though, "madness" is often depicted as either comedy, absolute psychopathy or pure randomness. While the cackling mad scientist, the axe-wielding killer and the oddball freak all have their place in certain sorts of games, it always saddens me when games which build in "realistic" psychiatric illnesses depict them so loosely.
Today's article examines two of the more common psychiatric illnesses that affect thought, from a point of view of the GM and the player character. The next article will discuss those that affect mood.
Whether you're playing a Malkavian vampire cursed by his blood, a Mythos investigator who has seen too much, or simply an ordinary person with a few interesting mental wrinkles, there should be something for you here. A skilled storyteller might be able to weave an entire game session around the idea that the player characters are suffering from psychiatric illness and are not realising it.
Schizophrenia
In Greek this translates as "split mind", which is probably why so often people confuse schizophrenia with multiple personality disorder. Schizophrenia is actually a very common problem, thought to affect 1 in 200 of the population, and is characterised by disorders of the thought process.
The condition is characterised by many features – historically we have used Schneider’s First Rank Symptoms to define schizophrenia. These include ...
- Thought symptoms – Thought broadcasting, interference, insertion, interruption and withdrawal.
- Auditory hallucinations – hearing thoughts spoken aloud, hearing voices referring to himself in the third person, hearing a commentary.
- Delusional perception – A delusion is an irrational and unshakeable belief.
- Feelings or actions experienced as made or influenced by external agents.
... which is all very nice, but what does it actually mean? This is probably easier to explain through an example.
Imagine you are at home watching the television on a quiet Sunday afternoon. Suddenly you hear an odd whispering noise coming from the speakers, not from the broadcast itself, but from the white noise beneath it. You switch the television to a dead channel and suddenly you can hear the voices more clearly. It's the government, muttering messages about control and obedience. There's also instructions there to your next door neighbours, the Patels, who you always knew were government spies because you heard them thinking about keeping an eye on you when you were listening up against the wall yesterday. You decide to go make a cup of tea to calm yourself. Of course, then you realise that you don’t really want a cup of tea, but are being made to want a cup of tea by the government broadcasts. Those bastards! They must have drugged your teabags! They're controlling your thoughts through the television! They're reading your thoughts through hidden receivers in the walls! There’s only one thing to do… smash the television, and cover the walls with cling film to block the signals.
Or another example ...
You're worthless, the voices in the head tell you. You're a dirty, miserable little idiot and you don't deserve to live. We've seen you, the voices say, when you looked at that fourteen year old girl in the park yesterday we heard your dirty worthless thoughts. We're not the only ones, either, the voices say. That middle aged mother who looked at you oddly? She could hear your dirty perverse little thoughts too. No wonder she scuttled away so quickly. Now we're going to punish you, by making you cut yourself. We know you don’t want to, but we’re going to make you do it anyway. You're worthless, the voices say.
Suddenly schizophrenia is neither funny nor zany. It's pretty harrowing to have to live inside a nightmare where you can't separate your rational and schizophrenic thoughts. In a game, a player depicting a schizophrenic should never be entirely sure if what the GM is describing to him is real or not. If he's role-playing properly the delusions part of the deal means that his reference points for deciding what is and is not real should shift as well. This can work really well in a game, especially in the horror genre where insanity is supposed to be frightening.
Of course, in modern settings there may be the option of antipsychotic medications to control or minimise the symptoms. This in itself can be a useful story device, as the character can be fairly safe and secure as long as he remembers to take his medicines, but when the circumstances of the story deny him these medicines, the GM can start to break down the borders of reality.
Many games also play off the theme that the "mad" have "true insight" that the sane lack, and can see the world beyond the world that really exists. I’d strongly recommend that if GMs use settings with this option, that they make these truths as disjointed and disturbing as the minds that are able to perceive them. A setting which regards schizophrenia as a desirable "gift" is, in my books at least, as tasteless as one which claims that people with cancer have a "gift".
Obsessive Compulsive Disorder
Another fairly common condition, and one which is often poorly depicted in RPGs, is obsessive compulsive disorder.
OCD is a neurotic rather than a psychotic condition, so those that suffer from it are usually totally aware that their behaviour is odd and abnormal, but really can't help doing the things that they do.
The main characteristic of OCD are (obviously) obsession and compulsion.
Obsession manifests in ritualistic behaviours and in preoccupation of thoughts. Certain things always have to be done in certain ways.
A classic activity of obsessive-compulsives is hand-washing. This doesn't normally mean repeated scrubbing in the style of Macbeth. Instead, an obsessive may feel the urge to wash his hands after the simplest activity, sometimes many hundreds of times in a single day. When he washes his hands he will do so in the same way every single time, perhaps attending to each finger in turn, checking under each nail, then finally taking a handful of water and splashing it over the tap to make sure it is clean as well.
Another common obsession is door checking. Most of us at some stage have doubled back to the car or the house to check that we actually did shut and lock the door. When we're anxious we check things more often – for example, when going to the airport on a long journey, most of us will check we have our ticket and passport far more often than we actually need to, just to reassure ourselves.
The obsessive takes this to the extreme degree. He will walk back to the door seconds after checking it, and when satisfied will walk away and only manage to get a few yards away before nagging doubt sets in. He'll then walk back and check again, and then he'll do it again, and again, and again. An obsessive might spend half an hour checking his front door. In an extreme case, an obsessive might check a door handle again and again from second to second, finding the motion reassuring.
The second half of OCD is compulsion. If a compulsive denies his urge to indulge his obsessions, then he will grow more and more anxious. If forcibly prevented from doing so, he may even have a panic attack, hyperventilating and crying. Of course, as soon as he satisfies his compulsion the anxiety fades, thus reinforcing the compulsive behaviour.
The important feature here is that obsessive-compulsives are not randomly obsessive. They have strict patterns and things that worry them. They will not feel the urge to count every grain of rice that is thrown before them, nor do they typically "fixate" on people and start stalking them. Both of these might make for good stories, but are not part of OCD proper.
Modern psychiatric thinking tries to treat OCD with the Cognitive Behavioural Therapy. CBT is actually very simple, and not nearly as creepy as it sounds from its name. It works on simple principles of operant conditioning. An obsessive-compulsive can gradually reverse his self-conditioned state, forcing himself to increase time gaps between compulsive behaviours, and allowing anxieties to fade more and more. He may also practice "thought stopping" techniques, which will allow him to redirect their train of thought. It actually works very well.
In an RPG, of course, such a dynamic is usually covered through willpower points or self control checks. This is an oversimplification of the complexity of OCD, but can function quite well.
OCD is extremely disabling and few players will want to roleplay out a condition that causes them so much trouble and which forces them into time-consuming routines. A better role for it in a game might be for a vital GM-controlled NPC to be suffering from the illness. If players lose their patience with the NPC and force him away from his obsessions, he may panic and lash out. If, say, he is a powerful Vampire or a talented Sorcerer, they may come to regret their actions.
The Heart of the Matter
Of course, disorders of thought don't stand alone. Any illness that affects thought processes has a strong chance of causing mood problems as well. Next month's article looks at problems of mood, and on role-playing matters melancholy.
Till then, happy gaming! And remember, the government is watching you through the computer.
