In a year packed with an eclectic mix of stunning, top-shelf cinematic video games, bizarre little indies and everything in between, I find myself worrying over the precarious personalities stuffed into my personal favorite game of the year.

Even now as I type this up, another screen is open to the game and the dozen characters I’ve been trying to cajole into playing for me.

My first string is in shambles, their nerves shot from one too many forays into the dungeons of my estate. They suffer from an array of maladies and budding personality quirks. They spend their down time in bars, brothels and the local abbey, preparing for another journey into their personal nightmares.

On its surface, Darkest Dungeon (Mac, Linux, PS4, Vita, Windows) is just another medieval fantasy game of exploration, discovery, fighting and looting. But it comes with a major twist: stress.

For years I’ve written and talked about how interesting it could be for a war game to include post-traumatic stress disorder as a game mechanic. Developers Red Hook did something just like that and the result goes well beyond anything I had imagined.

Layered on top of the typical stats found in a game like this (in this case, health, accuracy, protection, speed, etc, etc) is the incredibly vital stress statistic.

Stress shows up as a series of tiny, greyed out rectangles under a character’s name. The more stressed they become, the more of those boxes receive a white outline. When a hero completely maxes out their stress level, which raises during combat and exploration of the darkened dungeons, they essentially have a panic attack. That panic attack gives them either an affliction or a virtue. Afflictions take the shape of anything as harmless as a fear of the dark to as problematic as being intensely self-serving. Virtues offer an equally broad range of quirks. The more you play, the more your character stresses and the more of these quirks pop up. All of these quirks bring with them direct impact in behavior or stats.

Increased stress can also lead to a higher chance of contracting one of the many diseases in the game like syphilis, tetanus or “spasm of the entrails.” All of which bring with them their own negative effects.

Reducing stress involves assigning characters to tasks at the bar or the abbey. Curing afflictions means a trip to the sanitarium. All of which costs money and takes those characters out of rotation for awhile.

Eventually the game morphs from one of dungeon exploration and combat, to one of personality management and care-giving.

My current roster (the difficulty of the game leads to an unfortunately high turnover rate) isn’t that problematic yet. But I’ve had in the past some real doozies. Like a Vesta, whose main purpose is to heal the injured in the party, who would only heal herself and do so without giving me a chance to direct her actions. Or a crusader so proud that he refused to be healed by anything or anyone.

As you play the game with your increasingly troubled characters, they start to do a lot of muttering. Words pop-up in cartoon bubbles over their heads about how unfair life is for them, or how stupid everyone else on the team is. Even in town they began to talk to you. My highly stressed Vestal, for instance, keeps saying “In through the nose, out through the mouth” as she, I assume, takes deep breaths to quell her fear.

If you are in a dungeon with characters fully stressed out, all of their rectangles now outlined in white, and you manage to double down on their stress, filling those outlines solid, they literally have heart attacks and die on the spot.

The sudden death of comrades in a dungeon can, I’ve learned, cause more stress. I once lost nearly an entire team of combatants to a string of fatal heart attacks.

Darkest Dungeon doesn’t lean completely on this mechanic of blossoming psychosis, it also has an interesting story and a reason for playing. You are meant to clean out the dungeons under your family’s estate and restore order to the area. The exploration and the battles are tactically driven and fun to chew through.

It’s just enough of a carrot to keep you playing, all the while knowing that your best and brightest may suddenly succumb to death by fatal blow, heart attack or even the myriad diseases the game’s creators worked into the dungeons. (Managing a team with a syphilitic egomaniac crusader as its leader is no walk in the park, let me tell you.)

The chief reason Darkest Dungeon is my game of the year, though, isn’t simply because I’ve played and enjoyed it so much. It’s because it’s proof that tackling real-world, unpleasant issues in a game can indeed make for much more compelling titles.

Without stress and the psychological impact of warfare, Darkest Dungeon would have been just another role-playing game lost in a sea of similar titles.

Instead, it’s a darkly compelling title that touches as much on tactics as it does the humanity of warfare and the complexity of the human psyche. It shows that the repercussions of combat isn’t always death, sometimes it’s something much more subtle.

Darkest Dungeon thrives as proof to other developers, I hope, that spending time to enrich a game with touches of real-life issues isn’t just a morally responsible thing to do, it can be an artistically-driven creative choice that turns a potentially generic title into someone’s game of the year.

Good Game is an internationally syndicated weekly news and opinion column about the big stories of the week in the gaming industry and its bigger impact on things to come. Brian Crecente is a founding editor and executive editor of Polygon.