Very disturbing game... But lack of acting skills.
It could have done better with expressions and speech acting... Even though all the games have poor acting. But this didn't really matter to me much.
The story was well thought out, the graphics were well done, and the music was very good. The way the creatures and scenery of the levels were really great. The Nurses were my favorite, based on their appearance, movements, and sounds. Red Pyramid Thing (aka Pyramid Head) had a really nice weapon of choice... because just hearing the scraping sound of it against the ground, was just enough to send the hair on the back of your neck to rise.
Lastly, the puzzles were very reasonable, not too hard, and not too easy... even though you could change the settings on difficulty.
This game had been well worth my time to play.