The film recreates a survivor-horror video game universe full of gruesome monsters and a bloodthirsty cult with an unnamed god: One prominent creature is a tall male executioner called Pyramid Head who wields a gigantic sword while wearing an iron pyramid helmet covering his head; we also see several pale, veiny-legged faceless nurses covered with blood and gore and armed guards wearing dark hazmat suits, helmets and gasmasks; cells in an asylum are filled with maniacal humans that scream, shout, and reach through the bars threateningly and grid-covered floors in the asylum are bloody and full of pale, bald humans that scream, with some dead, bloody humans and body parts and a few human skulls; indistinct warriors appear occasionally and they have sharp round blades growing vertically and horizontally through their heads at eye and ear level and in one scene a human woman turns into one of these creatures and in another scene a hobo changes into one of these creatures and then back into a hobo; two humanoids have gaping, bleeding wounds where eyes should be and several humanoids have long incisions in their faces and/or rear skulls that are sewn with gaping stitches -- on one male humanoid, the stitches take up the whole face; and several black-armored ghosts appear briefly on a bridge.
At a mall food court, the kids at a birthday party change into zombies that eat blood-dripping sandwiches of dark red meat (some looks like indistinct human organs), a clown's face becomes evil as he pursues a teen girl briefly, and in one of the kitchens the girl sees a live teen boy suspended like a carcass from the ceiling as a blood-covered butcher carves a huge piece of bleeding flesh from his abdomen and chest, showing his rib cage and slashed organs; the boy is screaming with his head encased inside a plastic zipper bag and a blood-covered cook nearby stirs a pan of something unknown on a blood-covered stove.
In a nightmare, an indistinct humanoid with blades through the head kicks through a man's back and out the chest, splashing blood and gore and the scene ends.
A flashback depicts a girl screaming as two men break into her house and her father stabs one, releasing a lot of blood.
A humanoid with blades growing through its head cuts off the fingers of a man's hand with a lot of blood and grabs him off screen; later, we see an area cordoned off and a body under a white sheet on a gurney.
In a dark basement storage room full of mannequins, one bagged female dummy begins to breathe and opens its eyes, while a teen girl screams; a woman covered in plastic groans and the girl untangles her when a spider made of mannequin arms and legs holding 3-4 dummy heads for eyes chases the girl and woman and cuts the woman's head off as she screams; the spider approaches the girl, opens up a dummy head and roars through a circle of bloody teeth in the head surrounded by gore as the girl runs away.
An executioner with an iron helmet and a huge knife-like axe cuts off the arms of several male inmates along a corridor of detention cells in an asylum (we see blood, gore and the cut end of bones as the inmates scream in pain).
Several slimy looking, faceless nurses in a hospital attack human asylum visitors with large knives and a huge squirting hypodermic needle.
A nurse cuts a guard wearing a hazmat suit in the shoulder, releasing a spray of blood, stabs another guard in the eye with a long kitchen knife, and unsuccessfully tries to stab a teen boy on a gurney; blood splashes on the camera lens and the boy escapes with a teen girl, but guards chase them unsuccessfully.
In a dream, and later in a scene in an abandoned carnival in a small town, small fires burn in trashcans at night as a teen girl enters the area and lights turn on and rides begin to operate themselves: hooded cult members march through the midway, stuffed animals on the midway all have bloody mouths and the fish in fishbowls in a stall float dead in dirty water, pale corpses hang from slings of rope where some of the carousel's horses should be and one corpse breathes and groans; a pyramid-helmeted man drags a giant sword through the carnival site, and in the dream, the teen girl catches fire and her clothing and hair burn off as she screams and then awakens.
An old man in chains in a dungeon has milky irises and says he's blind as he takes a medallion from a teen girl and jams it into his chest while she holds a handgun pointed at him (we see blood and hear squishing): the man changes into a tall, pale and faceless creature with long arms and carries her away until she reaches into his chest and pulls the medallion from a tangle of blood vessels, shoots the creature several times and he dies; she then walks down a hallway where she is accosted by a man with the top of his face ripped away and shoots him several times (he dies).
A teen girl runs to a carousel that is soon ignited in a ring of fire, cult members burn to death for a few seconds.
A teen girl confronts a demonic little girl on the carousel, then morphs into a dark doppelganger of the teen girl.
A teen girl is grabbed by her neck by a dark doppelganger of herself, having her skin turns pale, flaky and cracks.
A carousel descends beneath a ring of fire.
A teen girl and her dark doppelganger hug each other on a carousel for dominance, in an attempt to absorb one another.
A teen girl absorbs her dark doppelganger, making them one complete person.
A teen girl arrives in a small town in an alternate reality where there is a dilapidated prison, and the girl sees visions of people being burned at the stake with crowds shouting, "Burn, witch!" and two women are shown tied to iron crosses with ropes in crucifixion style and we see three charred bodies of people still attached to poles where they were burned; we see a little girl burned but alive on a stake after the fire has been extinguished, and her skin is pale and flecked with ashes.
A dead woman appears to her husband as a captured spirit in a mirror, standing on a foggy street.
A little girl with staring eyes walks down a street that becomes all ashes and blood.
A woman touches a medallion, she begins to emit black smoke and changes into a warrior with round steel blades growing through her head; the warrior battles using a sword with an executioner and his huge knife-axe, and they stab and slash, both losing a lot of blood that splatters over floors, walls and each other until one slices the other's head off in close-up amid a shower of blood and drags his knife-axe away silently.
In a nighttime carnival scene, a guard grabs a teen girl and drops his gasmask that causes him to gasp and bleed from the eyes, nose, ears and mouth (he falls and lies still on the ground, presumably dead).
In a high school corridor, we see a poster of a women's face with a moth covering her mouth and nose, indicating a transformation into something macabre; the hallway changes into a bombed-out corridor with dirt, rust and blood on floors and doors and the lights spit and flicker.
A teen boy and a teen girl drive to a motel and inside a room we see the walls leaking bloody lesions and disintegrating, leaving a rusted out frame of a building; something indistinct grabs the boy and the scene cuts to the next morning when the girl awakens to find the motel restored.
Elementary school kids shove a little girl around in the middle of a circle of children as the girl cries; a bloody, faceless, bald humanoid creature, nude but without sexual details, charges the girl, she screams, and the area changes back to normal.
A teen girl returns home to find her father missing and a message that reads "COME TO SILENT HILL" written in dripping blood along with a cult symbol.
A teen girl walks trough an open door and finds a cult sanctuary lit by torches where her dad is tied to a large faceless statue and a woman demands a medallion from the girl and says her dad's blood will soon feed a newborn god.
A teen girl with a lead pipe threatens a man until he backs off.
A teen boy and a teen girl see a psychotic old man on a city bus that grins and speaks loud gibberish.
A teen girl and a teen boy argue several times about truth and lies, reality and fantasy.
We hear police detectives say that a teen girl is a murder suspect, because they found her bloody coat in a crime scene.
A teen boy says that his mother had his grandfather committed to a mental institution.
In a flashback, a little girl cries when told her mother died.
We see X-rays that show a skull with blades stuck through it at eye and ear-level.
A man keeps a wooden box of information and hand drawn pictures of creatures from a cult and the top of the box is carved with a mystical symbol of three circles inside a larger circle.