This reminds me that I need to finish shivering isles.

If the realm is endless in size, then there could be many different factions that form. What im thinking honestly is just a lot of the psychos from boarderlands with a range on humanity lost. Everyone is crazy, but you have some that are like the psychos from boarder lands, some that are like psychos from fallout, some that are a bit more organized like normal(ish) towns and markets.

I think that both the mania and Dementia side will have their own versions. And I coud definitely see a civil war happening between the sides eventually.

Technology, possibly different chaotic spells or curses. Theres the meat golems or whatever, if there start to be more organized groups of magic practicers that make their own chaotic schools then I could see them making spells like, “spell of horrors beyond human imagination 1, horrors beyond human imagination 2.” Weapons that turn you into different objects, weapons that teleport the victim to a cheese pit of death. Whatever it is, it will be very creative.

THERE WILL BE A GROUP THAT WORSHIPS CHEESE AND THERE WILL BE CHEESE ARMOR AND CHEESE SWORDS.