Failing a Sanity roll always causes the investigator to lose self-control for a moment, at which point the Keeper should choose an involuntary action for the investigator. For example:
A fumbled Sanity roll results in the character losing the maximum Sanity points for that particular situation or encounter.
In Call of Cthulhu, insanity is induced by traumatic experiences and the ghastly comprehension that connects to the Cthulhu Mythos. The duration of the insane state depends upon the number or proportion of Sanity points lost.
Three states of insanity can result: temporary, indefinite, and permanent.
Regardless of whether the insanity is temporary or indefinite, it will consist of three distinct game phases:
First: the insanity begins with a brief “bout of madness,” during which the player’s control of their investigator is compromised (see Insanity Phase 1: A Bout of Madness, page 156).
Second: the bout of madness is followed by a period of underlying insanity, during which the player retains full control of their investigator; however, the investigator is prone to delusions, phobias, and further bouts of madness (see Insanity Phase 2: Underlying Insanity, page 158).
Third: the final phase is recovery (see Treatment and Recovery from Insanity, page 164).
If an investigator loses 5 or more Sanity points from a single source of Sanity loss (e.g. a Sanity roll or reading a tome) sufficient emotional trauma has been suffered that the Keeper must test the investigator’s sanity. The Keeper asks for an Intelligence (INT) roll. If the roll is failed, the investigator has repressed the memory (a trick the mind uses to protect itself), and does not become insane. Perversely, if the INT roll succeeds, the investigator recognizes the full significance of what has been seen or experienced and goes temporarily insane. The effects of temporary insanity begin immediately and last for 1D10 hours.
On losing a fifth or more of current Sanity points in one game “day,” the investigator becomes indefinitely insane. No investigator is simply able to shrug off this amount of sanity drain. A “day” in this instance is defined by the Keeper, usually lasting until the investigator reaches a place of safety in which they can rest and recover their wits. Depending on the situation, it may mean surviving until dawn, sitting down for a nice cup of tea, or having a good night’s sleep. Indefinite insanity lasts until the character is cured or recovers (see Recovery from Indefinite Insanity, page 164).