The true Curse of Caine, some vampiric theologians say, is not the hunger for blood but agelessness. Cainites have before them an eternity of nights without release, centuries of fighting back the howls of the Beast and watching all they care for crumble to dust. Already saddled with the animalistic rages within them, Cainites often fall victim to other forms of dementia and lunacy. In some clans (notably the Malkavians) derangements are endemic, while members of other clans gain them as result of mental trauma. In most cases, they reflect an inability to accept the world at face value, resulting in a twisted perception of reality that better suits the character's mental capacity. Some characters have these quirks at the start of play. Others accumulate them during game play at the Storyteller's discretion, usually after periods of intense stress, terror or anxiety.

Derangements are not intended to straightjacket a character, although they unquestionably create challenges for the player and her companions to solve. They also provide opportunities for dramatic roleplaying and storytelling. Madness is a very real part of the Dark Medieval, and those who suffer from it are variously seen as cursed or blessed. In many cases, they respond to outside stimuli in a manner that makes perfect sense to them but is odd to outsiders who do not comprehend their frame of reference. Derangements should not be arbitrary in their effect, but linked to their own internally consistent set of rules. Most often these rules are linked to the origins of the character's derangement and should be agreed upon by the player and Storyteller. For example, a fear of flames might come from the vampire being tortured with fire by an inquisitor. A neonate might develop a perfectionist nature if her sire punished her severely for being sloppy.

The system effects of derangements vary from case to case. They usually result from having botched a Virtue roll or experienced a truly traumatic event. When appropriate, the Storyteller can ask a deranged character's player to roll Self-Control or Instinct to resist a derangement overcoming the character when presented with relevant stimulus. The difficulty ranges from 5 to 8 depending on the power of the stimulus.

  • Amnesia: Amnesiac characters blot out some part of their past, perhaps even a horrific incident (for exmaple their Embrace) or even a whole period in their lives. The reasons for this memory loss are almost always stress-related, though physical injury may cause a similar effect. Amnesia usually affects just memory, but in some cases, a character may forget some Abilities and be unable to use them, or be surprised by his ability to do certain things. (Amnesia may be represented by its Flaw)
  • Catatonia: A character suffering frmo this derangement may withdraw frmo the world entirely at times of stress, remaining largely immobile and unresponsive. Due to the major limiting factors on their actions, catatonia is not recommended as a player derangement.
  • Fantasy: Some characters cannot accept the real world, so they transpose themselves into an illusory world instead. The scope and degree of this fantasy varies considerably. A character may hold conversations with characters who aren't there, or hear "voices from the gods" commanding him to carry out a wide range of acts. He may also interact with people and institutions of the Dark Medieval in an almost normal manner but with their perception of events skewed by their fantasy. For example, a Cainite may regard himself as Lancelot from the Arthurian legends, on a quest to slay a vile demon or rescue a fair princess. Such fantasies manifest as a quirky outlook, but they are rarely dangerous (unless the Cainite believes that he can walk about in the daylight…). They can, however, adversely affect the character's reaction to others, perhaps making them more likely to frenzy ("They are Mordred's get, milord!") or determined to carry out a mad assault ("The grail lies this way!")
  • Hysteria: Hysterical characters are unable to control their emotions, and they suffer from severe mood swings. A hysterical Cainite will frenzy more easily than other vampires (increase the difficulty of his Self-Control/Instinct rolls by two), particularly when faced with great stress.
  • Lunacy: This madness comes and goes, linekd to the cycle of the moon. When the moon is full, the character is manic and delirious, while at the time of the new moon, he may appear normal and unaffected. His ability to resist frenzy and Rotschreck varies accordingly, increasing and decreasing by a point to reflect his mood.
  • Megalomania: Characters with this derangement believe that they are destined to lead, and they seek to accumulate power, irrespective of their skill and the attitude of others. They believe that those who dismiss their claims are jealous, seeking to hold onto power and deny them their dues. The megalomaniacs believe that these opponents should be destroyed, politically or physically.
  • Melancholia: Cainites with this derangement frequently slip into deep depression, losing interest in their normal activities and becoming withdrawn. When suffering from melancholia, the vampire's Willpower rating is greatly reduced (half, round up, the normal value) and they have difficulty becoming motivated. These depressive periods often follow failure of a particular action, though they may also result from hunger (a blood pool of one-quarter or less) or psychological factors.
  • Multiple Personalities: Something in the character's past has caused his personality to fragment into a number of distinct selves, each with its own traits, outlooks and agendas. The number and nature of these personalities should be agreed by the player and the Storyteller, as should matters such as the trigger to switch personalities (often emotional stress) and the knowledge each possesses. In Cainites, these personalities may exhibit different Virtues, traits and Disciplines, and they could even believe themselves to be of different Clans. However, only the Storyteller can decide if the skills exhibited by a personality are real or delusions.
  • Obsession: Obsessive characters become fixated on a particular activity, person or thing. They may seek to ensure all objects in their possession are categorized and sorted by type, or they may strive to keep their hands spotlessly clean and thus be constantly washing them. They may become fixated on feeding from a particular group of mortals, or in a particular manner, or they may seek to visit all the shrines of a particular saint. Whatever the nature of that obsession is, the target is the center of the character's existence. If he is denied access, he might become agitated.
  • Overcompensation: An overcompensating character attempts to make up for a flaw in her character (real or perceived) by stressing another aspect of her personality. This limits her actions and skews her perceptions of the world. She may take a "holier than thou" attitude toward others, lecturing them about their shortcomings, constantly attempting to take the moral high ground. If the character's own flaws are revealed, the embarassment would be acute and her reaction unpredictable.
  • Paranoia: They are jealous of you, or scared. They want to do you in and end your unlife! Paranoid characters believe that they are the victims of persecution, either by an individual or a group. They are very wary of social interactions (+1 difficulty to all Social tests) and fearful that others are in league with their tormentors. Even the slightest thing can trigger a paranoid episode, prompting the characer to withdraw into himself or even strike out in fear. Of course, just because a character is paranoid doesn't mean there aren't people out to get him…
  • Perfectionism: Perfectionists seek to control every aspect of their unlives, often following a rigid set of rules intended to ensure that everything "runs to plan." All their efforts are directed to ensuring that things happen as intended, and if they don't, the perfectionists become agitated, possibly even entering frenzy.
  • "Possession" Sanguinary Animism): This uniquely Cainite derangement leads sufferers to beileve that they drink the souls of their victims as well as their blood. They believe their victims communicate with them as voices in their head or memories seeping into their consciousness. In some cases, the sufferer blames his actions on these voices, claiming that they are an effort to pacify his tormentors.
  • Regression: Characters suffering from regression also have difficulty accepting the real world. However, rather than retreating into fantasy environment, they retreat into a more simplistic mentality, often that of a child. Such characters are usually heavily dependent on others, both for tasks and decision-making. They are frequently naive, which may be a boon or a curse depending on the circumstances. This refuge of youth may be permanent, or it may kick in as a result of stress. Some characters retreat even further when placed under great pressure, their mental faculties completely shutting down and leaving them to operate on instinct alone. These episodes result in blackouts and periods of memory loss that may be roleplayed, with the character acting on instinct subject to predetermined set of guidelines, or abstracted, with the character coming to her senses with no recollection of the last few minutes/hours/days.
  • Saint Vitus's Dance: Technically a disease of the nervous system (known in the 21st century as Sydenham's chorea) rather than a derangement, the effects of Saint Vitus's Dance are thought of as a form of madness by the inhabitants of the Dark Medieval. It causes involuntary movements of the face and limbs, resulting in a face-like series of movements that persist for days or weeks and then disappear, sometimes permanently but often reappearing after months or years. Often a result of rheumatic fever, Saint Vitus's Dance can spread throughout a group, leading to mass outbreaks of the "madness." Unlike most mortal diseases, Cainites can suffer from Saint Vitus's Dance, which they contract via infected blood.
  • Visions: This derangement leads sufferers to believe that they are granted insight into the divine through visions, trances and other ecstatic states. During these spells, they may be catatonic, in a trance-like state or rave uncontrollably. Their ability to recall details of the visions is similarly varied, sometimes recalling precise details while having only the vaguest recollections of others. Some details may not resurface until days after the revelation, emerging in response to some external stimulus. These visions may be products of an overactive imagination, or they could, at the Storyteller's discretion and very rarely, reflect a real insight into the unknown.