When he wakes up after "dying", Thomas finds himself in a psychiatrist's office with Gabrielle Smith sitting at a desk. Thomas' only option is to enter an occupied cell and then succumb to death by the dweller. Near the end of the nightmare, Thomas will be forced to walk on broken glass and alert a nearby patient. Patients roam some of the hallways to make things slightly difficult, and a few corridors also have broken glass on the floor that can be evadable or avoidable. All of the hallways have cell doors, most of which Thomas can inspect to show the inside of the rooms. As the nightmare progresses, the rooms gradually become more bloody and gruesome, with even a few corridors having large piles of dismembered corpses. The nightmare primarily involves Thomas navigating the hospital's numerous hallways and rooms. After all the noise dies down, the door of Thomas' cell opens, allowing him to leave. Shortly after getting out of bed, a ruckus of screaming and objects breaking occurs outside the cell. The nightmare begins with Thomas Smith waking up inside a padded room with a bed and a barred window. The image that represents this nightmare on the Nightmare Select screen is a close-up of a cell door. It takes place in what appears to be a Victorian-era psychiatric hospital. Insanity is the fourth nightmare in the game Neverending Nightmares.
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