When a character is distressed and takes more stress they draw an Insanity card.

If they draw an appropriate card they place it down in front of them with...zero tokens?

So a character will only retain the insanity if:

• They are distressed
• Gain another stress
• Draw an maddness that befits the situation
• Gain MORE stress, while distressed to put tokens on them.
• Then later, fail the roll to discard that Madness.

If that is a correct assestment then that is a a ridiciously complex process to retain madness.

Found that in the FAQ, you place some default tokens on the madness card when received. This gives the mechanic a little more bite.