Afflictions of the mind have always been with us. As medical knowledge advances, it becomes apparent that about 20% of the population will experience some form of illness requiring psychiatric treatment during their lifetime. This value seems to be constant across a wide range of cultures and technology levels.
The majority of mental illnesses are reactions to adverse situations experienced in life, from the horrific to the merely strange.
Most first become manifest in early adulthood. Some underlying predispositions exist. The question of 'nature vs nurture' would appear to be irrelevant. Inherited factors, mainly dealing with neurochemistry and perception are as important as personality styles developed during childhood and adolescence.
- Anxiety and the neuroses
- obsessive-compulsive disorder (OCD)
- post-traumatic stress syndrome
- Disorders of mood
- bipolar disorder
- Disorders of reality perception
Anxiety and the neuroses
Anxiety is a normal physiological response in anticipation of a potential stressor. The body and mind become primed for 'fight or flight'; breathing and pulse quicken, senses are on full alert. It is very useful - up to a point. Beyond this limit, it becomes counter-productive, even destructive. Headaches, abdominal pain, palpitations, nausea, vomitting, diarrhoea, 'pins and needles' in the extremities, and a general feeling of impending doom are symptoms of a severe anxiety attack.
We can regard anxiety disorders as arising from
- Inappropriate stressors
- Inappropriate threshold for initiating anxiety response, or
- Inappropriate response to stressors.
- We usually remember bad events rather than good ones. This would appear to be an ineradicable part of human nature. A particularly stressful event may lead to a fear of objects, concepts or situations which remind one of that occurrence. Most people have little quirks of this sort e.g., fear of the number 13, insects, needles, etc. Most people can control the anxiety these stressors generate. However, some cannot.
- Post-Traumatic Stress Syndrome
- This is very similar to a phobia. The provocative event is usually awful (e.g., losing a spouse or a close friend in horrific circumstances). Situations can arise much later in life which trigger an uncontrollable, vivid episode of recall (colloquially, a 'flashback'). These are often disabling in their intensity.
- Obsessive-Compulsive Disorder (OCD)
- The normal routines of daily life, and the requirement for some baseline level of vigilance in one's affairs is by and large taken for granted. These are things which happen almost automatically.
- An undue focus on certain of these tasks, and an abnormal fear of the consequences if these tasks are not successfully completed, characterises OCD.
- Key elements
- Rituals - certain activities must be done in the same way, every time, otherwise disaster will ensue, e.g., handwashing with a fresh bar of soap (no-one else's germs could be on a fresh bar of soap). Rituals may be interlinked, e.g., counting or tapping out a beat to ensure hands are washed for just the right amount of time.
- Repetition - rituals must be completed many times a day to prevent disaster striking, e.g., handwashing after touching each utensil used to prepare food.
- Rumination - thinking centres around what needs to be done to prevent a disastrous outcome. These thoughts often bubble along under the surface, and are a considerable distraction, e.g., Have I washed the dishes? Are they clean? I'll have to check... No, safer to wash them again, just to be sure...
- Fear of uncleanliness or infection is a common symptom complex. Rituals can range from minor (must wash hands for EXACTLY sixty seconds) to socially difficult (bringing own eating utensils to a restaurant).
- Jack Nicholson's performance in "As Good As It Gets" is a good portrayal of OCD symptoms, apart from the occasional display of disinhibited behaviour.
Disorders of Mood
It is normal to experience a wide range of emotions, from joy to sadness to anger and a myriad of shades in between during one's life. Blunting of this response is not.
- The most common severe psychiatric disorder, depression is a sustained state of sadness far beyond that considered usual for a given precipitant, with disabling symptoms.
- Fatigue, wide variations in sleep requirement, eating patterns, and general feelings of inadequacy or worthlessness are some common symptoms of depression.
- In severe cases, withdrawal from social contact can be almost total. Thoughts of worthlessness, guilt, and even physical decay remain uppermost in the mind, or become increasingly difficult to banish.
- Psychotic depression arises when one's experiences and sensations are inappropriately filtered through this haze of negative thoughts. ("I cannot open my bowels ; if I go to the toilet, the stuff will explode and destroy the city" - a quote from one of the more memorable mentally ill people I have interviewed).
- Bipolar Disorder (a.k.a. manic-depressive disorder)
- Mood alternates between severely depressed and excessively elevated. This latter state is known as mania.
- Your thoughts move very rapidly ; it's often difficult to express them to other people, they're flying so thick and fast. It is difficult to concentrate on a given topic. Even seemingly unrelated ideas will be interconnected, somehow. (It's just that everyone else can't think at your level). Eating and sleeping aren't terribly important. You've never felt so alive. You can do anything, anything at all. Behaviour is disinhibited and can be quite impulsive, inappropriate and uncharacteristic, e.g., excessive spending, drug abuse, sexual activity. Bank accounts and reputations have often been devastated during manic upswings.
- Cycling between depression and mania is unpredictable initially. Those that survive long enough (suicide in 20-30% of those affected after five years, untreated) tend to settle down into a more regular pattern.
Disorders of Reality Perception
One's concept of self, and the way the world would appear to work, evolves over time. By adulthood, most people have a stable, broadly similar 'model of the outside world' and 'self concept'.
Some however, do not. Stressors ranging from the demands of work or study, or some drugs of abuse (e.g., amphetamines, LSD) can wreak havoc on these vulnerable persons. The consequences can be profound and tragic.
- A global disturbance of perception and thought. Emotional expression is blunted or inappropriate for a given situation. The thought processes become ponderous, but disconnected almost to the point of randomness. Hallucinations - abnormal interpretations of ordinary sense data - are commonplace.
- It is quite easy for life's ordinary events to acquire undue significance and/or bizarre explanations as a result, e.g., the mailman comes by every day because he is watching me... Paranoia - the delusion that everyone else wishes (to do) you harm - is a relatively common feature of schizophrenia. It can also be seen in psychotic depression and delirium (see below).
- Such thinking is regarded as delusional when it is impossible to convince someone that these ideas are inaccurate to some extent (if not wildly incorrect), regardless of the assembled evidence.
- Like depression, eating and sleeping requirements can vary wildly. Like OCD, rituals and rumination are commonplace. Unlike either of these two illnesses, insight - the recognition that there are abnormal thoughts and behaviour - is usually absent.
- A common occurrence during other illnesses, e.g., after major surgery. Orientation to time, place and person is usually lost. The actions of people nearby are often interpreted in the most negative way (e.g., "The nurse is here to kill me" or "You've broken into my bedroom! Get out before I call the police!"). Risk factors include severity of illness, extremes of age, sensory impairment (blindness, deafness), sedative medications, drug withdrawal, unfamiliar environment, sleep deprivation (especially common with busy ICUs), etc. Delirium is usually self-limiting unless dementia is present, in which case it may be the initial event leading to the eventual diagnosis of dementia.
Falling Ill: Game rules
As mentioned earlier, early adulthood is the most common time for psychiatric illnesses to become manifest. For gaming purposes, it may be easiest to have a flat 20% chance of developing some problem during character generation in the first three terms.
- To avoid developing a mental illness
- Average, (Int+End)/2
This task is rolled once each term during character generation. The level of difficulty drops to Easy in the fourth and subsequent terms
Increase the task difficulty by one level if
- survival roll almost fails, dishonorable discharge, or heroic behaviour (post-traumatic stress?).
- fails college or other advanced education (cause or effect?).
- abusing psychoactive drugs (moderate to severe central nervous system stimulants or depressants).
On failure, roll 2D for disorder
Developed Mental Illness
|Roll on 2D||Disorder|
|3 - 4||Bipolar Disorder|
|5 - 8||Depression|
|9 - 11||Anxiety Disorder (phobia or Post-traumatic stress syndrome)|
|12||Obsessive-Compulsive Disorder (OCD)|
For Depression, Anxiety Disorders (other than Post-Traumatic Stress Syndrome), or OCD, roll 1D for severity
Anxiety Disorders, or OCD
|Roll on 1D||Severity|
|1 - 3||Mild|
|4 - 5||Moderate|
All other disorders (including post-traumatic stress) are severe.
Referees and players are strongly reminded that these effects need to be role-played!
For Anxiety Disorders, the triggering factors need to be specified. Roll the following task each time one or more triggering factors occurs.
- To avoid having an anxiety attack
- (difficulty), (Int+End)/2
The severity of the disorder affects the difficulty of the task, the effect of failure of the task, and the type of trigger.
Difficulty of Avoiding Depression or Anxiety Attacks
|Severity of Disorder||Difficulty Level of Task||On failure||Type of Trigger for Anxiety||Type of Trigger for Depression|
|Mild||Average||Impose DM -1 on all tasks attempted for duration of attack.||Strong, e.g., skydiving for first time||Weak, e.g, favorite team loses championship|
|Moderate||Difficult||Make all tasks attempted during attack one difficulty level harder (i.e., Average becomes Difficult, Difficult becomes Formidable, etc.).||Average, e.g., blind date, job interview||Moderate, e.g., loss of livelihood, eviction from residence, long-term disability|
|Severe||Formidable||Make all tasks attempted during attack two difficulty levels harder.||Inappropriate, e.g., opening front door and stepping outside||Strong, e.g., death of close friend or relative, permanent disability|
Additionally, 1 point per day for duration of depression or anxiety attack is taken from Str, End or Dex to simulate fatigue.
On Spectacular Failure of avoidance of depression or anxiety, impose 2D (total) against Str, Dex, End promptly to represent decompensation.
For OCD, use the above task (Difficulty is Formidable, trigger severity as Anxiety) to avoid falling into ritualistic behaviour.
For Post-traumatic stress, use the above task (Difficulty is Formidable, trigger severity as Anxiety) to avoid flashback.
For Bipolar Disorder, use the above task for depressive phase, imposing
penalties as for depresion.
For manic phase, add one point to Str, End, Dex and Int. All tasks are one level easier, unless concentration and/or computation are required, in which case they are one level more difficult.
All of the above penalties apply until the triggering factors are removed or otherwise dealt with.
A Difficult, End check is made at the end of each week of a mood swing due to Bipolar Disorder to see if it has run its course.
Success or spectacular success : normalisation of mood.
Failure : continues
Spectacular Failure : Severe swing to other extreme (i.e., depression becomes mania, mania becomes depression).
This task should also be rolled at the end of each week of an anxiety attack or depression until the triggering factors have been removed or otherwise addressed.
Until treatment is obtained, roll 1D each month to determine mood.
1-2 depressed, 3-4 normal (interlude), 5-6 manic.
Schizophrenia :- Int and Edu suffer a -2 penalty.
All tasks are one difficulty level harder. These penalties are an attempt to reflect thought disorder and hallucinations. Task failure may lead to extreme agitation or catatonic stupor on Spectacular Failure (dice randomly). (+2 to physical attributes if agitated ; cannot initiate any actions if catatonic).
Treatment and Cure of Mental Illness
Psychiatry has its beginnings in the 'scientific revolution' which is regarded as one of the features of Tech Levels 3 to 4 on standard indices.
Prior to this, the mentally ill were regarded as blessed or cursed by the gods and warehoused, ignored, revered, or reviled accordingly.
Competing theories of the genesis and progression of mental illnesses arise.
Initially, psychotic disorders are treated most vigorously, with methods ranging from intensive talk therapy through to electroshock, drug-induced comas and lobotomy (TL 4-5).
By Tech Level 6, effective treatments have arisen for depression and schizophrenia. Medications control most of the worst symptoms but have other unintended side effects on the cardiovascular and nervous system which are often severe. Minor tranquillisers are widely used to treat anxiety.
By Tech Level 8, it is apparent that anxiety disorders and OCD are best treated by a combination of cognitive-behavioural therapy (problem behaviours are identified and strategies devised to usefully modify or eliminate them) and mild psychoactive medication. The biochemical and neurophysiological bases of schizophrenia and depression are beginning to be seriously explored during this period.
Increasing knowledge in the fields of molecular biology and neurophysiology yield highly effective treatments for depression and schizophrenia by TL 12. These medications are very selective and thus have no 'spill-over' side effects. (TL 12 ; tens of milligram potencies ; moderate nervous system stimulants or depressants ; rare allergy or intolerance (Major or Destroyed damage on Spectacular Failure of catastrophe check); safety margin 50 ; abuse potential low). However, treatment is required for life with schizophrenia and severe depression.
Brain-computer interfaces and memory reading are developed at TL 14. One of the first uses of the technology is in clinical psychiatry in an attempt to treat refractory mental illnesses. The destructive nature of the reading process, combined with the lack of control over rewriting, soon leads to the abandonment of the technique in legitimate medical circles. It is entirely possible that certain technically advanced but socially repressive societies use such methods to stifle political dissent or punish other 'criminals'.
Given the reputed success of psionically oriented societies such as the Zhodani in treating psychiatric illnesses, a lot of medical research is devoted to perfecting technological 'mind reading and reconstruction' in the Imperium, despite the prevailing cultural climate.
Game Rules Governing Treatement of Mental Illness
Psychiatrists are doctors with high skill (at least 3) in Psychology and Interview. Psychiatric nurses need at least skill 2 in Psychology and Interview.
- To diagnose mental illness
- Average, Medical, Edu, uncertain
Modifiers to Uncertainty
|TL7 - TL8||+2|
|TL9 - TL11||+3|
On Spectacular Failure, apply -2 DM to treatment task.
On Spectacular Success, apply +1 DM to treatment task.
- To treat mental illness
- (illness severity), Medical, Edu, uncertain
Difficulty of Treatment
|Severity of Illness||Difficulty of Treatment|
Apply the following modifiers to both success and uncertainty rolls
Modifiers to Mental Illness Treatment Tasks
|(severe depression) electroshock therapy used||+2|
|psychoactive medications used (available at TL6+)||+2|
|cognitive behavioural therapy used (available at TL7 or TL8)||+2|
|psychoactive medications used (available at TL12+)||+5|
|talk therapy used on psychotic illnesses||-3|
|drug-induced coma for any illness||-2|
Electroshock therapy and drug comas are equivalent to general anaesthetic, and require appropriate precautions.
On Failure, make a catastrophe check. If the catastrophe check fails, the character has attempted to hurt himself
On Spectacular Failure, the character has attempted to commit suicide. The referee should specify the circumstances and result.
On Spectacular Success, the patient's recovery rate is improved by one level.
Damage Imposed on
|Severity of Illness||Damage Imposed on Failure|
Recovery : as per trauma rules, dice for a random amount of damage or use points penalties described earlier, e.g., for depression.
Costs : psychiatric care is equivalent to hospital ward or home care in this regard. The home care figure is for a psychiatric nurse's visit.
Additionally, twice a week, a psychiatrist must be consulted. This costs 50Cr for a half hour session.
Notes and Miscellany
Psychiatry is an important branch of medicine. It unfortunately provides oppressive cultures with another means of controlling the populace. Dissidents can be labelled 'mentally ill' and be 'hospitalised'. Psychoactive medications can be used as adjuncts to interrogation. Psychosurgical methods can be used to ensure obedience, or at least suppression of 'problem behaviours'.