When the game was released, it was criticized for including references to the real-life death of Elisa Lam, a woman who disappeared in early February 2013 and was later found dead in a cistern. Her case has been noted for containing bizarre similarities to the early 2000's Japanese/American horror film "Dark Water", and has been referenced and studied in other places in international pop culture.

During development, the mother of the game's lead designers Brian and Andrew Allanson was diagnosed with cancer, which eventually resulted in her death. This led the team to rework certain parts of the game's plot, aiming to have "a more 'humanistic' perspective" and "sand down some of the game's more cynical edges". By the end, nearly a quarter of the game had been remade, including a slight change to the game's ending.