Thursday, March 17, 2022

Optional D&D Roleplaying Rules for Compulsions

I came up with these rules awhile back, as a way to help me roleplay some of my own characters, and recently put them to use for the first time in a session and they worked great. So I'm going to explain the rules, and then talk about how that session went.

For characters that are supposed to be affected by compulsions that make them want to behave in ways that are incompatible with their moral code or who they see themselves as, which are supposed to be difficult but not impossible to resist, it can be hard to figure out a way to properly represent these in-game, if you want more guidance than simply roleplaying the effect yourself. This can be especially problematic when the effect is assigned by the DM to a PC, such as when a magical effect causes a PC to gain a new flaw.

For simple, immediate impulses, making a Wisdom saving throw (DC set by PC) to resist the urge to immediately do a thing could be appropriate - eg, while a hungry vampire is hugging a living humanoid, they might make a Wisdom saving throw and on a failure make a bite attack against the person they're hugging. Similarly, if an alcoholic has a cup of alcohol in front of them, they might make a Wisdom saving throw or take a swig.

However, for actions that take multiple rounds, and especially ones that take planning, it's a lot harder to represent them with a single Wisdom saving throw. Eg, for an alcoholic who doesn't happen to be right next to an alcoholic beverage, how would you represent the process of them going to a bar, ordering a drink, and drinking it, despite their desire to quit drinking?

In 3.5, many of these effects are represented by ability damage - the Book of Vile Darkness has ability damage due to withdrawal from addiction, and the Libris Mortis has ability damage for undead with an unfulfilled desire or need to feed on the living. However, this has always felt unsatisfying to me. For addictions, it's quite plausible that a character could go into withdrawal, become incapacitated, and then recover, without ever feeling like you might not be able to prevent your PC from seeking out their addiction. Libris Mortis has the Inescapable Craving type of undead hunger result in uncontrollably seeking out the object of their hunger if they reach 0 Wisdom, but it's no harder for a wraith at 2 Wisdom to resist draining life than a well fed wraith. And for Diet Dependent undead, this clause only takes effect at a point at which they also lose the ability to move, creating a similar issue to drug withdrawal rules.

So, here’s my suggestions for how to go about representing an eroding will to not do multi-step activities your character feels compelled to do.

First, one option would be to do a Wisdom saving throw for each step, increasing the DC progressively with each failed save. For example, the alcoholic in withdrawal might have to do a Wisdom saving throw to determine whether they walk home past the bar, or choose a different route to avoid passing the bar. On a failure, they walk towards the bar, and then when they are about to pass it, they must make another Wisdom saving throw or enter the bar. They then proceed to make another Wisdom save or order a drink, and another Wisdom saving throw or drink it. Then they make another Wisdom save vs ordering a second drink, and so forth. This continues until they’ve either made it back out of the tempting situation, or drunk themselves to unconsciousness, or if something causes another urge to be stronger than the urge to drink (eg, if the bar catches fire, the urge to avoid burning to death will supersede the urge to keep drinking).

For a vampire, a similar sequence might look like first going to a popular place to meet a one-night stand, choosing a target, flirting with the chosen target, charming the target, getting the target alone and biting the target. Or whatever hunting strategy would most fit with that vampire’s character and/or prior history. Unlike the alcoholic ordering a drink, the vampire luring a one-night stand to bite has a potential to fail despite the vampire’s best efforts (e.g. if the target succeeds a save vs vampire Charm, or the vampire fails a Persuasion check along the way). In that case, the failure could elicit another Wisdom save vs the urge to try again (possibly on a different target).

Another option would be to represent the character’s will to not do the thing they want to do as a set of arguments against doing it. For example, the alcoholic might have a list like:

  • I’m risking liver damage
  • My ex-wife won’t let me see my kids if I can’t stay sober
  • I got fired from my last job for showing up drunk, and I want to keep my current job
  • I’d like to have money to spend on things other than booze
  • Getting drunk makes it easier for the assassins hunting me to potentially kill me

Then the PC ranks each of those reasons from most to least important for this character. When they feel a craving, they must make a Wisdom saving throw, and on a failure, they negate one of those reasons. For example, the alcoholic might decide that the other things they could spend their money on aren’t as worthwhile to them as getting drunk, or that they don’t really care about their liver’s health, or that their ex-wife will probably find some other reason to keep them from seeing their kids. This counterargument doesn’t have to be, and probably shouldn’t be, something a rational person would consider a good argument, but it’s one that feels compelling to that character, and pushes them closer to being willing to drink alcohol.
With either option, if the character satisfies their craving, they could revert to their initial state of being totally unwilling to satisfy their craving ever again, along with feeling really unhappy about their recent actions. Conversely, you could combine the two options by having them make saves against action sequences during a craving, and then upon satisfying the craving, make a save against losing a reason to not indulge the craving in the future. Each lost reason makes the DC against the first step of the action sequence harder in the future.
And now, how I put this in practice!
This takes place in our Westmarch-style D&D campaign where adventurers spend their downtime in a Planar City created by a silver dragon archmage. One of my PCs, Xalith Baenduis, is a drow who has been partially ceremorphosized, or turned into an illithid. (She's an aberrant mind sorcerer.) She's not illithid enough to actually need to eat brains, but she's illithid enough to feel a desire to eat brains, and due to a homebrew feat, she can also regain spent spell slots by eating brains. Meanwhile, I came up with the following list of reasons she doesn't want to eat brains (the numbers reflect the importance ranking):
  • It's gross. (#5)
  • I worry that acting more illithid-like will eventually make me lose my identity to the tadpole. (#1)
  • I'm friends with a githyanki who would be horrified by this behavior if she found out. (#2)
  • I might get kicked out of the Planar City if I'm seen as a threat to the other inhabitants. (#3)
  • The illithid might have an easier time finding me if they hear about brainless corpses being found. (#4)

Xalith and another PC of mine, a yuan-ti pureblood named Zsistla, were hanging out in Baldur's Gate, in a walled ghetto known as Little Calimshan, trying to deal with Zsistla being blackmailed into kidnapping a Calishite jewelry merchant to appease someone who caught her stealing a large sum of money from a merchant. Unfortunately, Xalith, as a drow, sticks out in Little Calimshan, and while they were trying to sneak around the neighborhood late at night, she got noticed by some thugs who decided to escort her out of Little Calimshan. She responded by trying to twin spell charm person, they both succeeded their saves, and a fight ensued.

Cut ahead several rounds. Xalith has successfully removed one opponent from combat using calm emotions, then ran around a corner and knocked the other opponent unconscious, but she knows reinforcements are coming. I considered fleeing with or without the unconscious goon. Without would be easier, but if she brought him with, she might be able to eat his brains. Cue a Wisdom save. I arbitrarily set the base DC to 12, and Xalith failed, so she proceeded to levitate while carrying the unconscious goon, hiding on a rooftop with him.

Next round, another Wisdom save failed, so Xalith takes out her dagger and tries to open his skull, but utterly fails. Rinse & repeat for another round. On the third round, with reinforcements getting closer, and her not very well hidden (I rolled badly on nearly every Stealth check Xalith made that whole session), she finally succeeds the Wisdom save and abruptly decides that no, she does not in fact want to eat this guy's brains, she wants to GTFO now.

She regroups with Zsistla, and we try and utterly fail to kidnap their target, and then decide to go hide somewhere and rest for 4 hours (long enough for a short rest for Zsistla and a long rest for Xalith, since we've interpreted the trance racial feature as allowing 4 hour long rests). Unfortunately, we come out of our hiding spot to find we're surrounded by goons, led by Rilsa Rael, an NPC the DM took from the Murder at Baldur's Gate premade adventure. There's far too many for us to fight, so when Rilsa Rael decides to start asking questions, Zsistla spills the beans.

Turns out Rilsa Rael is willing to team up with us to double-cross Zsistla's blackmailer, so we happily agree - we were intending a double-cross anyway, and allies make that double-cross much safer. Part of the agreement is that we should lead Rilsa to where we stashed their missing goon. Miraculously, it turns out that he survived, and Xalith silently feels deeply relieved that she didn't have to try to explain (to both Zsistla and Rilsa) why the guy's head was cracked open and his brains eaten. The rest of the session goes smoothly, and we finish off with a blackmailer defeated, some information for Zsistla about his connections and motivation, and Rilsa as a friendly contact willing to give us a favor sometime because we helped her deal a serious blow to a rival gang the guy was affiliated with.

Xalith hasn't actually eaten a brain yet, so I didn't have a chance to see if she decided brain-eating isn't actually gross at all. But I've seen benefits to both parts of the system, now.

As a character-building exercise, figuring out all the reasons why Xalith doesn't want to eat brains gave me a much clearer sense of her personality. Note, for example, that moral objections aren't on the list, because she's chaotic evil. But the fact that fear of becoming more illithid is number 1 has clarified for me that in general, Xalith is deeply afraid of losing what shreds of her identity she's managed to hold onto so far. The fact that her memories of her previous life are full of gaps, her trance now involves visions of eldritch vistas with a giant elder brain (Ilsensine), and her instincts are different now worries her, and the thought of changing even further absolutely terrifies her. This tells me a lot of stuff that's useful to understanding her even when she's not craving humanoid brains.

And in actual play, figuring out component steps and rolling a Wisdom save for each one really helped me create a scene where she almost succumbs to the urge and then catches herself. In that situation, the steps I had in mind were a) bring the goon somewhere private, b) open up his skull, and c) eat his brain. So, she could have succeeded in shaking off the urge at any of those steps, and since she failed step b) several times, she got several tries at it. If I had actually rolled better than a 5 on my dagger attacks with advantage, though, I could have gotten his skull open. At which point, would she have actually eaten his brain? I'll never know. I know I loved the uncertainty of not actually knowing if she'd be able to stop herself from eating his brains, and I loved how the failed saves, failed attacks and finally successful save created a story of almost succumbing to temptation that I probably wouldn't have been able to come up with on the fly by myself.

I did forget about my intention to increase the DC with each failure for a point of no return, but it didn't actually matter, because my successful save was well above the cutoff.

Tuesday, March 15, 2022

Rejection Sensitivity, ADHD, and Quackery

To hear people talk about it, rejection sensitive dysphoria, also known as rejection sensitivity, is unique to ADHD. I even saw toxic people on Tumblr accusing non-ADHD people who described their experiences with rejection sensitive dysphoria as "culturally appropriating" (even though ADHD isn't a culture, it's a neurotype, and neurotypes are inherently arbitrary categorizations). And on a Google search for rejection sensitive dysphoria, the first six results discuss it in association with ADHD, with only the sixth result mentioning any other diagnosis that could be associated with RSD. Google also reveals the person who seems to be responsible for the belief that RSD is unique to ADHD - William Dodson.

But what does the research literature say? Is rejection sensitivity unique to ADHD?

This is actually two questions in one. First, are people with ADHD more likely to experience intense negative emotions from rejection, and secondly, are intense reactions to rejection common in any other clinical group?

ADHD and Rejection Sensitivity

Canu & Carlson (2007) studied NT, ADHD-C and ADHD-IA men in undergraduate university, and did not find significant differences in rejection sensitivity, assessed via self-report questionnaire, between the three groups.

Motamedi et al (2016) studied kindergarteners who either met criteria for ADHD, showed subthreshold ADHD tendencies, or were neurotypical, and assessed “rejection reactivity” by having the children customize an abstract shape as an avatar and then watch their avatar play with another shape, and then get abandoned for a third shape. Afterwards, they were asked how the video made them feel and how intense their feeling was, and those who said they felt “a lot” of a negative emotion were classified as rejection reactive. Hyperactivity, but not inattentiveness, was correlated with rejection reactivity.

Apart from these two studies, I wasn’t able to find any other publicly-accessible studies of rejection sensitivity in ADHD. Overall, it seems like there’s mixed evidence regarding whether or not rejection sensitivity is associated with ADHD.

Rejection Sensitivity in Other Clinical Groups

Unsurprisingly to anyone who knows anything about borderline personality disorder, rejection sensitivity is clearly correlated with this condition. I found many studies of BPD and rejection sensitivity, three of which are described below.

Ayduk et al (2008) studied the correlation between borderline personality features, rejection sensitivity, and executive control in several general population samples, and found that the combination of low executive control and high rejection sensitivity predicted higher borderline personality features.

Meyer et al (2005) studied borderline personality features and their association with rejection sensitivity measured both by a questionnaire and reactions to a vignette of an ambiguous social situation that could be interpreted as involving rejection, in a heterogenous general community sample. Borderline features were associated with rejection sensitivity as measured by both the questionnaire and the vignette.

Barros (2016) assessed borderline personality features and rejection sensitivity in staff and students at a university, and found a significant correlation between the two, indicating that individuals with more borderline personality features were more sensitive to rejection.

Depression is also, unsurprisingly, associated with rejection sensitivity. Here’s several studies:

Waller (2015) studied 11-17 year olds with major depressive disorder compared to mentally healthy controls, and found that self-report rejection sensitivity was significantly higher in depressed teens.

Bondü et al (2017) studied 9-21 year olds in a 1-2 year longitudinal study of several dimensions, including depression and two types of rejection sensitivity - anxious and angry (divided by what negative emotion rejection elicited). Participants with higher depression symptomatology were higher in both types of rejection sensitivity at both times. However, the association between time 1 rejection sensitivity and time 2 depression (controlling for time 1 depression) differed by type - anxious rejection sensitivity was associated with increases in depression over time, whereas angry rejection sensitivity was associated with decreases in depression. Meanwhile, time 1 depression was associated with increases in both types of rejection sensitivity by time 2.

Ng & Johnson (2013) compared adults with bipolar I who were currently in remission to mentally healthy individuals, and found that the bipolar participants had higher rejection sensitivity. However, when current depression symptoms were controlled for, this difference disappeared. On 6 month follow-up, rejection sensitivity predicted increases in depression symptoms but not mania symptoms.

There’s also some other diagnoses that came up in a few studies.

In addition to borderline features as mentioned above, Meyer et al (2005) also studied avoidant personality features and their association with rejection sensitivity measured both by a questionnaire and reactions to a vignette of an ambiguous social situation. Avoidant personality features were very strongly correlated with rejection sensitivity in the vignette, and less strongly but still significantly correlated with rejection sensitivity using the questionnaire measure.

Keenan et al (2018) studied autistic traits and rejection sensitivity in university undergraduates, and found that the two were positively correlated, indicating that individuals with more autistic traits were more sensitive to rejection.

In conclusion, rejection sensitivity is definitely not exclusive to ADHD, and it’s unclear if it’s even associated with ADHD at all. Rejection sensitivity appears to be primarily associated with depressed mood states and with borderline personality disorder, and possibly seen in other conditions such as autism and avoidant personality disorder.

So why do people think it is?

In my impression, there’s a lot of quackery in the ADHD world, and it seems to have a unique flavor. ADHD symptoms can be associated with a variety of underlying causes, and sometimes it’s more accurate to describe a person’s ADHD symptoms as simply manifestations of another condition, rather than as true ADHD. However, it seems like ADHD “specialists” rarely consider any differential diagnosis for ADHD, and instead treat variation in symptomatology in ADHD as different types of ADHD.

A good example is the book Healing ADD: The Breakthrough Program that Allows You to See and Heal the 7 Types of ADD by Daniel Amen. If you look through Amen’s seven “types of ADD”, defined by fMRI and symptoms, a lot of them sound suspiciously like other conditions that should be considered in differential diagnosis. “Ring of Fire” ADD is defined by an fMRI pattern that is highly distinctive and unique to an acute manic episode, not ADHD/ADD, and the symptoms described seem more fitting with mania, as well. Meanwhile, overfocused ADD sounds like obsessive-compulsive disorder or an anxiety disorder, temporal lobe and limbic ADD sound more like different flavors of depressive disorders, and anxious ADD sounds like - you guessed it - anxiety disorders. Whether or not these cases actually do have ADHD in addition to these other conditions is unclear, but in any case, symptoms of other conditions in a person with an ADHD diagnosis should be addressed and assessed directly, not treated as just “subtypes of ADD”.

I think William Dodson is cut from similar cloth as Daniel Amen - another ADHD “specialist” who forgets that ADHD isn’t the only possible explanation for his patients’ symptoms, and neglects to look for any other psychiatric conditions that might explain the symptoms he’s observing.

Of course, ADHD isn’t the only neurodivergence that’s riddled with quacks. Autism has plenty of quacks, too, although their tactics are generally different. The biggest difference I’ve noticed is that autism quacks tend to be liked by NT parents of autistic kids and absolutely detested by actual autistic people, whereas ADHD quacks seem to be able to get the respect of their actual patients and not just their patients’ parents. This means that the social justice heuristic of “nothing about us without us” is far less effective at weeding out quackery in ADHD than in autism.

However, autistics should take this as a caution. I’ve seen more and more autism “experts” who are paying lip service to listening to autistic voices, meanwhile still peddling misinformation that could be harmful to autistic people. As we gain more power and influence, the quacks could start to pay more and more attention to marketing directly to us instead of just to our families.