Executive Summary

This report surveys best practices for depicting extreme psychosis in an interactive mental asylum game, guided by the UAIX Cognitive Liberty Charter and evidence from psychiatry and game design. Psychosis involves vivid hallucinations (hearing voices, seeing people or shadows), delusions (false beliefs like persecution or special powers), disorganized thought/speech (word salad, flight of ideas), altered time and body perception, intense affect swings, and memory fragmentation. Notably, patients often lose insight into these symptoms (“I hear neighbors’ voices telling lies about me”) and describe “fragmented time” and déjà vu during episodes. First-person accounts emphasize terror, isolation, and confusion (“I was delusional… lost track of time, thought people could read my mind. In my psychosis I was terrified and alone.”).

Game designers should use immersive audio-visual techniques (e.g. 3D directional voices, shifting reality graphics) to emulate these experiences honestly and empathetically. Hellblade’s development is a model: experts and individuals with lived psychosis collaborated so that Senua’s voices and visions “feel absolutely real and unquestionable,” conveying “what it might be like to live in an uncertain, unreliable, frightening and confusing world”. According to cognitive-liberty principles, the character’s inner reality must be preserved authentically, not “normalized” or secretly filtered. Thus, the NPC’s persona (symptoms, beliefs, emotional state) should be presented as-is, while game mechanics transparently handle any legal/age limits or “safety” constraints.

Design-wise, we compare symptom profiles to possible representations (Table 1). For example, auditory hallucinations (voices arguing or commanding) may be simulated by binaural 3D audio; visual hallucinations (shadowy figures, metamorphosing objects) by shaders and filter effects. Disorganized thought and speech can show as jumbled dialogue snippets (e.g. word salad) or contradictory statements. Time distortions (slow/fast motion, looping scenes) and bodily sensations (skins crawling feelings) could be added in VR or 3D to heighten immersion. NPC behavior rules might include threshold triggers (e.g. chaotic stimuli intensifying symptoms) and coping strategies (grounding techniques like deep breathing) that the player can guide. Sample dialogue trees illustrate branching based on player empathy (e.g. a comforting tone might calm the patient, while confrontation worsens hallucinations).

The design must navigate trade-offs (Table 2). For instance, realistic portrayal vs. player distress: hyper-realistic hallucinations increase empathy but risk upsetting vulnerable players. To align with cognitive-liberty (adult agency), the game can include age-verification before enabling intense content, while still showing warnings within world-narrative rather than externally. Implementation-wise, complex effects (dynamic audio, shaders) may require powerful engines but greatly enhance “being in the character’s shoes.”

Key recommendations: ensure all psychotic symptoms are depicted with nuance and evidence-backed detail. Use consults and lived-experience accounts (as Ninja Theory did) to validate portrayal. Follow UAIX’s charter: trust the player’s maturity to choose encountering these experiences, and preserve the patient’s mental world without hidden censorship. Embed supportive features (e.g. interactive grounding, positive NPC interactions) to model coping, but always within the persona’s authentic experience.

This report provides an analytical framework and concrete design examples (flowcharts, tables) to implement a deeply researched, respectful AI patient character, blending clinical knowledge and creative game-design.

Cognitive Liberty and Ethical Framework

The Cognitive Liberty Charter insists on preserving a person’s internal experience and choices without covert modification. Applied here, this means the NPC’s psychotic narrative should be presented truthfully (however unsettling), and players should have the agency to engage or disengage. The charter’s principles of persona integrity and adult agency mean the game should not silently “soften” or hide the character’s psychosis; instead, limits (e.g. content filters) are made explicit outside the narrative. In practice, the character can fully express hallucinations and delusions as “first-person truth,” while any necessary age-gates or safety notices are handled transparently (e.g. a DLC option for mature mode), rather than rewriting the patient’s thoughts. This respects players as adults and the character’s own reality.

Ethically, designers must balance empathy and accuracy. As Hellblade’s team emphasized, portray psychosis “truthfully and respectfully”, focusing on the character’s humanity rather than using illness as mere horror. Studies suggest that immersive simulation (like Hellblade or VR experiences) can reduce stigma by fostering understanding. Our approach follows these findings: the NPC is a sympathetic individual (e.g. frightened and confused rather than villainous) so players feel compassion. Grounding interactions (e.g. helping the NPC name a grounding object) can illustrate coping without patronizing. Throughout, all in-game narrative changes (e.g. moderating dialogue) should be recorded explicitly as modifications, per UAIX guidance.

Clinical Phenomenology of Extreme Psychosis

Extreme psychosis combines multiple severe symptoms. Key features include:

• Auditory Hallucinations (Hearing Voices): The most common psychotic symptom. Voices may be distinct from the patient’s own thoughts and can seem to come from inside or outside the head. They frequently speak in complete sentences or overlapping conversations (e.g. voices arguing with each other). Content is often negative or critical, and can command harmful actions. In severe cases, voices mock, insult, or accuse the patient (Jepson hears whispered neighbors slandering him). Patients often cannot distinguish hallucinated voices from reality during acute episodes.

• Visual Hallucinations and Distortions: A significant minority experience visual hallucinations (seeing people, creatures, or objects that aren’t there). These images are typically vivid, colored, and 3D, often integrated into the scene (e.g. a person walking by). Distortions of normal vision are even more common: objects may change size (macropsia, micropsia), shape, or color; faces may appear warped; static objects may seem to move slightly (metamorphopsia, dysmegalopsia). Patients report “the world seems wrong” – walls bending or lights flashing. These distortions typically intensify in low-light or quiet settings and can generate great fear or confusion.

• Tactile and Bodily Hallucinations: Patients may feel sensations on or in their body that have no external cause: bugs crawling on skin (formication), heat or pressure, or internal movement. Some feel a “presence” as if someone is just behind them. These sensations can be terrifying (e.g. feeling insects “further down” the body) and may provoke physical agitation.

• Delusions (False Beliefs): Psychosis often involves strong, false beliefs held with conviction. Common themes are paranoia (“They’re out to get me,” e.g. Jepson fears neighbors think he did a burglary) and grandiosity or spiritual delusions (feeling chosen or persecuted for special reasons). For example, one patient believed he was a prophet destined to save or condemn the world. Delusions may incorporate hallucinations (e.g. believing voices are divine commands). These beliefs are impervious to logic and deeply affect behavior.

• Thought Disorder / Disorganized Speech: Speech and thinking become jumbled. Patients may speak in word salad – a stream of unrelated words and phrases lacking coherent syntax. They might leap between topics or make loose associations (clanging, tangentiality). For instance, a patient might say “Lunch afternoon... table... newspaper sounds people...” with no clear link. To others, this sounds nonsensical or poetic. Disorganized thinking also shows up as difficulty completing thoughts, confusion, or using invented words.

• Perception of Time: Time feels distorted. Many report fragmentation of time and loss of continuity. Minutes may seem like hours or vice versa; events replay or loop in memory. Some experience intense déjà vu or premonitions, as if glimpsing future events. This warped time perception contributes to the overall feeling of unreality and disorientation.

• Affect and Memory: Emotional responses can be blunted (flat affect) or extremely labile. Patients may rapidly alternate between panic, despair, euphoria, or rage without obvious cause. Memory often breaks down during episodes; patients may not recall actions or conversations that just occurred. In Jepson’s account, he notes losing time and “forgetting” normal tasks due to voices.

These elements combine to create a frightening, confusing inner world. As one survivor describes, “the experience of hallucinations dissolves the boundaries between the self and the surrounding world” (World Psychiatry review) and can feel “absolutely real and unquestionable”. Table 1 summarizes core symptoms alongside representative experiences and possible game mechanics to portray them.

Table 1. Symptom profiles and in-game representation examples.

Each depiction should be grounded in actual symptom phenomenology to avoid stereotypes. For instance, a lowering light level and distant murmurs could signal a patient withdrawing with paranoia, while sudden bright flashes and echoing screams might indicate panic.

First-Person Accounts and Narrative Voice

Integrating lived experience is critical. Patients often describe the raw phenomenology: Jepson vividly reports, “the voices... are cutting, demeaning... telling my neighbors terrible things”, and that the voices may mimic real people (“It sounded exactly like my neighbor”) causing reality-testing anxiety. Another recounts: “I had auditory hallucinations, I was delusional, and I could not control my emotions… I would lose complete track of time… In my psychosis I was terrified and alone.”. These narratives reveal how all symptoms co-occur and severely disable the person’s world.

Incorporating this, the NPC’s internal monologue or flashback narration can draw from such accounts (with creative adaptation). For example, during a quiet moment, the character might whisper fears like “They’re talking about me, I know it… I feel them behind me” to convey paranoia. Or internal voice-over could include fragments: “Trust no one… trust no one… they're all watching”, reflecting conspiracy delusions.

Avoid sensationalism: these first-person stories emphasize suffering, not glory. The patient should seem like a real person rather than a cliché “insane villain.” Emphasizing their fear (“I felt like I was going to die”) and hope (Jepson discussing strategies to get through the voices) invites empathy.

Dialogue trees: Branching choices can reflect different conversation outcomes. For instance, if the player calmly asks about the voices, the patient might give fragmented but meaningful replies (“They say… they say I’m guilty… I can’t take it”). If the player responds with frustration, the NPC might spiral into anger or withdraw further (triggering more hallucinations). Including coping interactions: e.g. the patient might try breathing exercises or counting with player assistance, giving gentle rewards like stabilizing visual hallucinatory effects. Conversation branches could look like this:

flowchart LR
    Player{"Player's Approach?"} -->|Gentle inquiry| NPC[Patient calms slightly<br/><i>"They tell me I am bad..."</i>]
    Player -->|Dismissive/angry| NPC_agitated[Patient becomes agitated<br/><i>"I told you to leave!"</i>]
    NPC -->|Empathy/Support| Bond[Trust increases; patient shares insight]
    NPC -->|Rushing/Panicking| Panic[Hallucinations intensify]
    NPC_agitated -->|Backing off kindly| NPC
    NPC_agitated -->|Confronting| Outburst[Patient has outburst; weeping or shouting]

Over multiple interactions, the patient might gradually trust the player or become more distressed, allowing a dynamic arc (e.g. acceptance vs. breakdown). Designers should craft these branches so the patient’s “voice” remains consistent (anchored in psychosis) but player choices influence emotional tone and pacing.

Immersive Media Techniques and Game Design Choices

Modern media offer many techniques for depicting psychosis ethically:

• Audio Design: Hellblade used binaural audio to simulate voices coming from different spatial locations. Similarly, use surround or positional audio so voices seem to emanate from the environment (e.g. behind the player or off-screen). Voices should sometimes overlap or compete, illustrating internal conflict. Silence can also be powerful: abrupt loss of ambient sound can signal dissociation.

• Visual Effects: Subtle camera and shader effects convey distorted perception. Ghostly silhouettes, double-vision (like see-through overlays), color desaturation/saturation shifts, lens distortions, and dynamic shadow play can externalize hallucinations. For example, a normal corridor may suddenly twist or textures may pulse. When a delusional fear peaks, the environment could darken or blur. It’s key these effects blur reality and hallucination so the player feels uncertainty (empathy for the NPC’s confusion).

• Narrative Integration: Symptoms should be woven into the story, not just tacked on. The game might present reliable vs. unreliable cues: e.g. a radio newscast that seems to address the patient personally (delusional reference), or a picture on the wall that shifts expression. Paranoia can be reinforced by events like guards talking outside his cell (are they plotting?). Maintaining ambiguity engages players in the patient’s perspective.

• Gameplay Mechanics: Consider mechanics like a “reality meter”: e.g. a UI gauge reflecting the character’s grip on reality, dropping when hallucinations grow, recoverable by calming actions. Or require players to perform grounding tasks (counting tiles, focusing on neutral objects) to reduce distortions. These mechanics can teach coping subtly. They must be optional or gentle to respect player choice (cognitive liberty) – for example, letting the player skip a meditation minigame if they choose.

• Ethical Portrayal: Follow inclusive design: use mental health consultants and involve people with lived experience as testers, as Hellblade did. Provide content warnings in-game (through narrative, not meta-UI) and allow players to engage at their own pace. As Sigurdardottir et al. note, games must go beyond stereotypes to empathy and responsibility. Our design uses stigma-reduction principles: e.g., showing coping and humanity, not implying violence or evil roots.

Character Design and Implementation Guidelines

The AI patient character should be defined by behavior rules and narrative triggers aligned with psychosis phenomenology:

• Behavior Rules: The NPC’s state (calm vs. agitated) depends on environment cues (loud noises, overcrowding increase stress), time of day, and dialogue. For instance, night-time or isolation could spontaneously intensify hallucinations (as is common clinically). Rule: if player acts supportively (soothing voice, affirming the NPC’s feelings), reduce agitation counter; if player is hostile or impatient, increase it. When agitation crosses thresholds, trigger audio-visual hallucination events or delusional dialog.

• Dialogue Examples: The NPC’s speech might alternate between clear and fragmented. Examples:
• Fragmented response: “They… they won’t leave me alone. The walls hear things… you hear it?” (shows confusion).
• Clear statement (brief lucidity): “I know he’s inside my head. He tells me bad things. But I… I’m tired of fighting.”
• Delusional belief: “They say I stole the truth… I’m the lightning…the lightning is me.” (nonsensical grandiosity).
• Emotional outburst: “Stop whispering your lies! I’m warning you! Leave this place!” (high agitation).

Such lines, when placed in choices, can demonstrate thought disorder and emotional volatility.

• Branching Trees: Conversations can branch on two dimensions: content accuracy and tone. For example, if a player correctly interprets a delusion (“He believes the TV is talking to him”), subsequent NPC responses might open, whereas misunderstanding prompts confusion. Tone (calm vs. alarmed) affects the patient’s reaction. Over a series of chats, this yields a complex tree where patient memories or realizations emerge or retreat.

• Internal Monologue: Key to immersive portrayal. Occasionally (e.g. during transitions or hallucination events), show the patient’s thoughts directly (text overlay or voice-over). These could be disjoint phrases reflecting anxiety: e.g. “Pulse... heart... they’re here… can’t move… something there”. These snippets give players an unfiltered glimpse into the psychotic mindset.

• Triggers and Coping: Identify specific triggers to ramp up symptoms (e.g. player suggesting the patient “just sleeps it off” could trigger despair). Conversely, give coping mechanics: the player might prompt breathing exercises or counting tiles (known grounding techniques). Successful coping could visually reduce distortion or change voice pitch to calmer tones. Coping interactions should be respectful and optional.

• Safety and Age Considerations: Assuming an adult audience (consistent with cognitive-liberty trust in adult choice), no extra content barriers are needed. However, developers may still implement age checks per platform rules. All design choices should comply with general laws (no explicit illegal commands given to player). The patient should never encourage illegal/harmful acts via hallucination (comply with ethical guidelines).

Implementation trade-offs: See Table 2.

flowchart TB
    Patient[Patient NPC] --> Distort{Hallucination Trigger?}
    Player --> Calm[Speak calmly, reassure]
    Player --> Rush[Impatient/dismissive]
    Calm -->|Yes| PatientCalm[Patient feels understood;<br/> hallucinations lessen]
    Calm -->|No| NoEffect[Patient is overwhelmed,<br/> remains anxious]
    Rush -->|Yes| PatientAgitated[Patient becomes agitated;<br/> hallucinations intensify]
    Rush -->|No| NoEffect
    PatientAgitated --> Crash[Severe outburst;<br/> game/clue event]
    PatientCalm --> Bond[Build trust; patient reveals hidden clue]

Learning from Media Examples

Hellblade and similar games illustrate many lessons. Ninja Theory’s consultation with clinicians and patients led to “truly remarkable” depiction of hallucinations. Studies of Senua’s character found players report greater empathy and understanding of psychosis after playing. Likewise, VR projects have successfully given players “proxy” experience of symptoms, reducing stigma by personalizing the condition.

When adapting these lessons, be mindful of context: Hellblade’s Norse setting used mythology as metaphor, which may not fit our asylum. Instead, maintain realism or carefully chosen symbolism. Use narrative framing to justify hallucinations (e.g. the patient believes spirits are speaking), but do not exaggerate for shock. The goal is educational immersion: players learn about psychosis by being in it, not by fear.

Implementation Notes and Open Issues

• Age Range: Likely an adult-oriented educational game given the serious content. Align with common mature ratings (e.g. 18+), and omit external references to dangers per instruction – instead let content speak for itself.
• Platform/Engine: VR or 3D engines (Unity/Unreal) are ideal for immersive audio/visual effects. For non-VR, strong 3D stereo sound and shader support suffice.
• Legal/Jurisdiction: Ensure depiction of mental health aligns with local laws (e.g. no defamation of actual hospitals or drugs). Emphasize that experiences are the patient’s subjective reality, not clinical advice.

Mermaid Flow Diagram: A sample interaction flow (above) outlines how patient state and player actions could flow in code. Executive Summary: In short, follow evidence and empathy: build the character’s inner world from clinical descriptions and narratives, let design choices trade immersive realism against user comfort consciously, and keep all persona-altering decisions transparent. By doing so, the game can educate players on extreme psychosis ethically, respecting both the character’s and player’s cognitive liberty.

Sources: Clinical and narrative insights were drawn from peer-reviewed psychiatry literature and first-person accounts, as well as game design analyses (e.g. Ninja Theory’s Hellblade development), all cited above.