A plague ravages the kingdom, setting the adventurers on a quest to find a cure. An adventurer emerges from an ancient tomb, unopened for centuries, and soon finds herself suffering from a wasting illness. A warlock offends some dark power and contracts a strange affliction that spreads whenever he casts spells.

A simple outbreak might amount to little more than a small drain on party resources, curable by a casting of lesser restoration. A more complicated outbreak can form the basis of one or more adventures as characters search for a cure, stop the spread of the disease, and deal with the consequences.

A disease that does more than infect a few party members is primarily a plot device. The rules help describe the effects of the disease and how it can be cured, but the specifics of how a disease works aren’t bound by a common set of rules. Diseases can affect any creature, and a given illness might or might not pass from one race or kind of creature to another. A plague might affect only constructs or undead, or sweep through a halfling neighborhood but leave other races untouched. What matters is the story you want to tell.

Sample Diseases

The diseases here illustrate the variety of ways disease can work in the game. Feel free to alter the saving throw DCs, incubation times, symptoms, and other characteristics of these diseases to suit your campaign.

Cackle Fever

This disease targets humanoids, although gnomes are strangely immune. While in the grips of this disease, victims frequently succumb to fits of mad laughter, giving the disease its common name and its morbid nickname: “the shrieks.”

Symptoms manifest 1d4 hours after infection and include fever and disorientation. The infected creature gains one level of exhaustion that can’t be removed until the disease is cured.

Any event that causes the infected creature great stress—including entering combat, taking damage, experiencing fear, or having a nightmare—forces the creature to make a DC 13 Constitution saving throw. On a failed save, the creature takes 5 (1d10) psychic damage and becomes incapacitated with mad laughter for 1 minute. The creature can repeat the saving throw at the end of each of its turns, ending the mad laughter and the incapacitated condition on a success.

Any humanoid creature that starts its turn within 10 feet of an infected creature in the throes of mad laughter must succeed on a DC 10 Constitution saving throw or also become infected with the disease. Once a creature succeeds on this save, it is immune to the mad laughter of that particular infected creature for 24 hours.

At the end of each long rest, an infected creature can make a DC 13 Constitution saving throw. On a successful save, the DC for this save and for the save to avoid an attack of mad laughter drops by 1d6.

When the saving throw DC drops to 0, the creature recovers from the disease. A creature that fails three of these saving throws gains a randomly determined form of indefinite madness, as described later in this chapter.

Sewer Plague

Sewer plague is a generic term for a broad category of illnesses that incubate in sewers, refuse heaps, and stagnant swamps, and which are sometimes transmitted by creatures that dwell in those areas, such as rats and otyughs.

When a humanoid creature is bitten by a creature that carries the disease, or when it comes into contact with filth or offal contaminated by the disease, the creature must succeed on a DC 11 Constitution saving throw or become infected.

It takes 1d4 days for sewer plague’s symptoms to manifest in an infected creature. Symptoms include fatigue and cramps. The infected creature suffers one level of exhaustion, and it regains only half the normal number of hit points from spending Hit Dice and no hit points from finishing a long rest.

At the end of each long rest, an infected creature must make a DC 11 Constitution saving throw. On a failed save, the character gains one level of exhaustion. On a successful save, the character’s exhaustion level decreases by one level. If a successful saving throw reduces the infected creature’s level of exhaustion below 1, the creature recovers from the disease.

Sight Rot

This painful infection causes bleeding from the eyes and eventually blinds the victim.

A beast or humanoid that drinks water tainted by sight rot must succeed on a DC 15 Constitution saving throw or become infected. One day after infection, the creature’s vision starts to become blurry. The creature takes a −1 penalty to attack rolls and ability checks that rely on sight. At the end of each long rest after the symptoms appear, the penalty worsens by 1. When it reaches −5, the victim is blinded until its sight is restored by magic such as lesser restoration or heal.

Sight rot can be cured using a rare flower called Eyebright, which grows in some swamps. Given an hour, a character who has proficiency with an herbalism kit can turn the flower into one dose of ointment. Applied to the eyes before a long rest, one dose of it prevents the disease from worsening after that rest. After three doses, the ointment cures the disease entirely.


In a typical campaign, characters aren’t driven mad by the horrors they face and the carnage they inflict day after day, but sometimes the stress of being an adventurer can be too much to bear. If your campaign has a strong horror theme, you might want to use madness as a way to reinforce that theme, emphasizing the extraordinarily horrific nature of the threats the adventurers face.

Going Mad

Various magical effects can inflict madness on an otherwise stable mind. Certain spells, such as contact other plane and symbol, can cause insanity, and you can use the madness rules here instead of the spell effects of those spells. Diseases, poisons, and planar effects such as psychic wind or the howling winds of Pandemonium can all inflict madness. Some artifacts can also break the psyche of a character who uses or becomes attuned to them.

Resisting a madness-inducing effect usually requires a Wisdom or Charisma saving throw.

Madness Effects

Madness can be short-term, long-term, or indefinite. Most relatively mundane effects impose short-term madness, which lasts for just a few minutes. More horrific effects or cumulative effects can result in long-term or indefinite madness.

A character afflicted with short-term madness is subjected to an effect from the Short-Term Madness table for 1d10 minutes.

A character afflicted with long-term madness is subjected to an effect from the Long-Term Madness table for 1d10 × 10 hours.

A character afflicted with indefinite madness gains a new character flaw from the Indefinite Madness table that lasts until cured.

Table: Short-Term Madness

d100Effect (lasts 1d10 minutes)

01–20The character retreats into his or her mind and becomes paralyzed. The effect ends if the character takes any damage.

21–30The character becomes incapacitated and spends the duration screaming, laughing, or weeping.

31–40The character becomes frightened and must use his or her action and movement each round to flee from the source of the fear.

41–50The character begins babbling and is incapable of normal speech or spellcasting.

51–60The character must use his or her action each round to attack the nearest creature.

61–70The character experiences vivid hallucinations and has disadvantage on ability checks.

71–75The character does whatever anyone tells him or her to do that isn’t obviously self-­ destructive.

76–80The character experiences an overpowering urge to eat something strange such as dirt, slime, or offal.

81–90The character is stunned.

91–100The character falls unconscious.

Table: Long-Term Madness

d100Effect (lasts 1d10 × 10 hours)

01–10The character feels compelled to repeat a specific activity over and over, such as washing hands, touching things, praying, or counting coins.

11–20The character experiences vivid hallucinations and has disadvantage on ability checks.

21–30The character suffers extreme paranoia. The character has disadvantage on Wisdom and Charisma checks.

31–40The character regards something (usually the source of madness) with intense revulsion, as if affected by the antipathy effect of the antipathy/sympathy spell.

41–45The character experiences a powerful delusion. Choose a potion. The character imagines that he or she is under its effects.

46–55The character becomes attached to a “lucky charm,” such as a person or an object, and has disadvantage on attack rolls, ability checks, and saving throws while more than 30 feet from it.

56–65The character is blinded (25%) or deafened (75%).

66–75The character experiences uncontrollable tremors or tics, which impose disadvantage on attack rolls, ability checks, and saving throws that involve Strength or Dexterity.

76–85The character suffers from partial amnesia. The character knows who he or she is and retains racial traits and class features, but doesn’t recognize other people or remember anything that happened before the madness took effect.

86–90Whenever the character takes damage, he or she must succeed on a DC 15 Wisdom saving throw or be affected as though he or she failed a saving throw against the confusion spell. The confusion effect lasts for 1 minute.

91–95The character loses the ability to speak. 96–100 The character falls unconscious. No amount of jostling or damage can wake the character.

Table: Indefinite Madness

d100Flaw (lasts until cured)

01–15“Being drunk keeps me sane.” 16–25 “I keep whatever I find.”

26–30“I try to become more like someone else I know—adopting his or her style of dress, mannerisms, and name.”

31–35“I must bend the truth, exaggerate, or outright lie to be interesting to other people.”

36–45“Achieving my goal is the only thing of interest to me, and I’ll ignore everything else to pursue it.”

46–50“I find it hard to care about anything that goes on around me.”

51–55“I don’t like the way people judge me all the time.”

56–70“I am the smartest, wisest, strongest, fastest, and most beautiful person I know.”

71–80“I am convinced that powerful enemies are hunting me, and their agents are everywhere I go. I am sure they’re watching me all the time.”

81–85“There’s only one person I can trust. And only I can see this special friend.”

86–95“I can’t take anything seriously. The more serious the situation, the funnier I find it.”

96–100“I’ve discovered that I really like killing people.”

Curing Madness

A calm emotions spell can suppress the effects of madness, while a lesser restoration spell can rid a character of a short-term or long-term madness. Depending on the source of the madness,remove curse or dispel evil might also prove effective. A greater restoration spell or more powerful magic is required to rid a character of indefinite madness.