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I'm not sure how exactly the insanity thing works. Is it just a cap on the number of kills? Is there actually a way to lower it? That seems like something the game should make a tad clearer. The way people poped in and out of existence was distracting and, when following a target, annoying. I think this was really interesting, but I feel like I just didn't get it.

Killing people reduces the player's mental health, and killing non-targets reduces it more. The screen slowly gets more post-processing until it gets to game over. But thanks for the feedback!