It’s a telling sign to let slip your winning hand before a game starts, but developer Ninja Theory does just that with their latest game, Hellblade: Senua’s Sacrifice. It’s right there in the opening screen, a warning that the game contains realistic depictions of psychosis–a mental illness signified by hallucinations, vivid breaks from reality, being constantly surrounded by voices, seeing patterns where there are none… The symptoms are long and horrifying, and the game makes heavy use of them. It’s the kind of thing that most creators would use as the twist at the end of the story, but Hellblade lays it all out.

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Hellblade makes sure you know right from the start that its main character, Senua, is severely mentally ill and trapped in a world of her own nightmares. There’s a certain leap of faith to play through a game where perception is a lie and any semblance of reality is fake. But then, that’s what games are, right? Vivid flights of fancy, trips to non-reality that let us escape the real world for a few precious hours at a time.

Ninja Theory first entered my orbit with Enslaved: Journey to the West, a PS3/Xbox 360 game that took the classic Chinese myth of the Monkey King and turned it into a surprisingly poignant post-apocalyptic romance. It remains one of my favorite games from that era primarily because it told a mature, intelligent story of a dysfunctional and fraught relationship between two people forced to be around one another. So, I came into Hellblade with high expectations.

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Still, the portrayal of mental illness in pop culture has always been disappointingly black and white, packed with misinformation, and mostly used for dramatic effect. In games, it tends to be a cheap mechanic; the quintessential “ghost in the machine” cliché to explain away extreme behavior (usually of the violent sort). In games, movies and TV, “crazy” people are often crazy just because they’re crazy.

Ninja Theory went well out of their way to research psychosis when designing Hellblade. They interviewed mental health professionals and both past and current sufferers of the same kinds of symptoms that Senua experiences in the game. The result is a visceral, violent, and stunning gaming experience.

Yet, by the same token, I’m not sure the end result was much different from any other game that creates horror from the concept of distorted reality. The roots of Senua’s mental illness are clearly spelled out over the course of the story, which weaves brilliantly dramatic Norse mythology with a history of horrible personal abuse and tragedy against its brutal Dark Ages backdrop. As a primer on the beliefs of ancient Vikings, Hellblade is easily one of the best things I’ve seen.

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Rather than elevating Vikings, the game makes no bones about the fact that these seafaring marauders destroyed the lives and the sanity of their foes. Senua suffers a total break from reality because of their brutality, sending her down a dark spiraling journey to the land of the Norse dead, Hel, to somehow save the soul of her dead lover.

In the game, the worst part of Senua’s psychosis is called the Darkness, some nebulous evil that causes pain and suffering wherever she goes. Throughout history, humans have often labeled anything different as bad, so it’s easy to understand how Senua would be an outcast in her own world.

Senua uses the mythology of her oppressors to create an internal world, to provide one last quest to throw herself into. Reality at her stage of misery is largely irrelevant. The game plays out with savage swordplay and strange illusion puzzles, both meant to represent aspects of how her illness presents itself. Mechanically, though, the game is still just using her unreliable perception as a means to an end–puzzles that require the player to find just the right angle to form optical illusions and monsters to slay at regular intervals to break up the pacing.

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The presentation, however, is stunning. While Hellblade features some of the most gorgeous graphics I’ve seen in this console generation, the audio work is even more astounding. Those voices are always there, revolving around you in surround sound, chiding and insulting, afraid, occasionally even hopeful and affirming, and frequently purposely annoying and disconcerting. You don’t need to be so damaged to identify with this aspect of Senua’s existence.

We all have voices in our head–call it your conscious or whatever you like–expressing doubt, ego, pain, panic. But here, they are amplified to the nth degree, overwhelming and unable to be ignored. Ultimately, Hellblade gives a genetic and behavioral explanation for Senua’s condition, but isn’t shy about the fact that everyone has a breaking point.

Such is the horror of mental illness, and Hellblade really delves into it. There are genuinely disturbing and frightening sequences here. It doesn’t matter if Hel is real or a figment of Senua’s imagination, because it feels real to her and to the player. That fear of the unknown, of whether or not reality is totally lost, is compelling and effective. Hellblade makes clear that once you slip through the door of questioning your reality, it’s hell to climb back through.

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If anything, the ending is of Hellblade is perhaps too positive—especially considering the nightmarish imagery and abuse—to feel entirely sincere. But this is fiction, after all, and maybe it’s not a terrible thing for players to see that even after years of torment, some things can still be overcome.