The entire beginning of the game is oppressively nightmarish to Lara, seeing as she's still somewhat of a well off fresh faced British chick thrust into a terrifying jungle landscape with no survival skills whatsoever, with insane cultists hunting Lara down through an unforgiving terrain that wants to keep them trapped on the island forever. Obviously she gets better at it, but still.
Some preview and review articles have mentioned that some of this game's particular death animations are EXTREMELY gruesome. The Kotaku review, in particular, has a very, VERY disturbing impalement animation planted in their review.
The entirety of the game has you trapped on an island full of insane, monstrous cultists that want to do horrible things to you and your allies.
The island is peppered with hundreds of sacrificed women still strung up in the shrines they were burned in.
The wolves that are sprinkled throughout the island that can leap out at you. In some cases, they'll leap at you in slow motion and if you're not able to put them down with a well-placed arrow, they will rip out your throat and break your neck.
There's one section in the game that finds Lara in a dark area that is littered with the various rotting remains of humans, blood splattered all over the walls.
There's also the reason why they are there in the first place. They are the tablescraps of an oni.
A scene that acts as a shout out to Apocalypse Now has Lara escape capture by jumping into a standing pool of human blood. As in completely submerged in it from head to toe. While she has open wounds, the most prominent of which being the gaping hole in her torso from being impaled at the beginning of the game. It doesn't help that this leads Lara into The Pit... All the fetid corpse-ridden water Lara wades through upto her nose. To put this in perspective, this is actually worse than the cover for Dead Island: Riptide which mirrors the scene, or any in game content. It's worse than Riptide, which drips Nightmare Fuel, is rated R and the trailer was banned. Yikes.
An early section of the game finds you fleeing from a deranged madman. If you're not able to get away from him, a large boulder will fall upon your legs, followed by another crushing your head.
The man himself is pretty damn creepy as well. He's not a whooping and hollering maniac. The way he speaks seems to indicate he wants to help you. Unfortunately, he wants to "help" you by sinking a climber's axe into your chest.
"Shhh... It will be over soon."
Really, the fact that the deaths are so startlingly brutal compared to the previous games.
It's not so much that they're more brutal, it's that Lara now looks photorealistic as opposed to more of an exaggerated cartoony type.
They also aren't anything you wouldn't find in a Dead Space game. Which really says it all right there: a Cosmic Horror game would be comfortable using the death scenes from this installment.
The "unholy ones" in the Pit. The sheer insanity they show with every word is unnerving in the extreme.
One QTE involves Lara sliding to avoid sharp sticks jutting out of a rapidly-moving river. If you fail, Lara gets gored through the throat. When Conan O'Brien tried this on his show, he failed repeatedly, leading to having to see the scene over and over again...with the audience clearly horrified each time.
Even worse, during the parachute scene, Lara will get skewered by multiple rows of sharp branches if you keep hitting the tree's. She'll twitch and struggle in excruciating pain until she gives out.
Towards the end of the game Lara must sneak past The entire Stormguard Army. The creepy chanting, inhuman roars and the painful consequences of being detected makes this encounter rather unnerving.
The No-Holds-Barred Beatdown that Lara receives midway through the game, is probably one of the most brutal depictions of the trope in recent gaming memory.
During Lara's first encounter with The Stormguard, she is captured and suspended in a chamber full of corpses and body parts. Once she manages to free herself, she starts crawling through a tunnel when The Oni Stalker enters the room. If Lara tries to go back into the previous chamber, then a scene is triggered where she is detected and smashed into a bloody pulp.
In the game, you can find two artifacts. These artifacts are toys. Yes, toys, and they belonged to two little girls: Coco and Millie. This alone is pretty horrifying in its own right. But then you remember what the Solarii normally do with girls on the island.
Before the toys are available to find, Lara is trapped in the Pit, a location in the Geothermic Caverns. This is an underground cavern where the Solarii imprison new male survivors, where they are psychologically broken, and either rot away or are initiated into the brotherhood. The cavern features some roaming prisoners that will attack Lara, and other prisoners stuck inside cramped cells. If the player gets over the initial primal fright of being jumped by the roaming prisoners (usually by killing them when they come at you), take the time to listen to the locked-up prisoners. Amongst the ones screaming in fear or anger, there is one guy that speaks calmly and to himself. He mentions that his family was shipwrecked on a sailing trip. His family that consisted of a wife and two daughters. The remaining monologue from the prisoner indicates that he may have seen his daughters, and possibly his wife, get killed in the fire ritual or by the Solarii's brutality. Whether the player learns this before or after the toys are discovered, it remains disheartening nonetheless.
The part with Lara climbing the old, rusty ladders of the radio tower is an absolute nightmare for those who are afraid of heights.
At the end of the game, when Himiko starts trying to possess Sam, the face of the statue she's encased in chips off, revealing her real, horribly decayed face. Which starts screaming.