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Madness Accelerant:

Great game. Everyone should play it, it isn't too difficult.

Here's how to get all four medals.

Facerape: When you last encounter the giant madness guy (he'll be crawling out of a doorway) use the saw on this head until it splits in half.

A Winner is You: self explanatory. Beat the game.

Pacifist: self explanatory. Let Tricky live. If you let him live, this will still count as beating the game and you'll get the aforementioned medal as well as this one.

True Face of Evil: When Tricky is down and crawling, waste all the ammo in your weapon so you only fight without a weapon and kick his mask.