The Hell Descent is the Otherworld manifestation of Dr. Fitch's fractured mental state. The environment contains metal, smoke, fire and fans that are ubiquitous to the other Otherworld locations of Silent Hill: Homecoming, as well as hospital references that are representative of Dr. Fitch's personal hell. At the end of Hell Descent, Alex Shepherd encounters Dr. Fitch and the manifestation of his daughter Scarlet.
As the name implies, this section of the game is symbolic of the character's descent into "Hell", specifically Dr. Fitch's personal one. The hospital signs, as well as the scattered dolls, are representative of Dr. Fitch's position as the town doctor and the overwhelming guilt he feels towards his daughter. It is also possible that the hospital imagery is symbolic of Alex's time spent institutionalized in a mental hospital. The descent is also symbolic of delving into the psyche, and could refer to the hidden emotions and guilt of either of the two men.
There are various false exits, usually denoted by exit signs. This can be representative of either of the two men confronting their repressed emotions. These false exits can also mean there was "no escape" for Dr. Fitch from his guilt, and was forced to live with his actions and memories forever.
Heat and fire are a constant theme, as embers can be seen throughout the area floating in the air, along with open furnaces and pipes dripping with what can be assumed is molten metal. This is likely added depth to the hellish industrial theme. Heat and fire are reminiscent of the Christian underworld, Hell, and can signify the punishment and overall feeling of sin that broke the psyche of Dr. Fitch and Alex.
There is also a return of the spinning fans, found in the other games of the series. Here it can be considered as a representation of things coming full-circle, such as realizing the death of Alex's brother or owning up to the murder Dr. Fitch committed.
- At some points, Alex will find dolls. If he examines them, they'll speak to him and in one instance, tell him to look behind him (a Smog will be there).
- On the bed at the beginning of Hell Descent, there is the shadow of a little girl. This may be where Scarlet was killed.
- For such a large area, the population of monsters are at an exceptional minimal. There are very few Swarms and the Smogs can be easily avoided by not investigating the dolls. This may be for emphasis on the fact that Alex is alone, searching within himself or Dr. Fitch. It may also emphasize that Doctor Fitch is literally alone, as he is the last Fitch alive (although not for long) and could foreshadow Alex being the last Shepherd alive.
- In the room right before the encounter of Dr. Fitch and Scarlet, the walls can be seen slowly oozing blood, reminiscent of Fitch's cutting problem. Ironically, this self-destructive behavior began occurring a short time before Fitch's death, and the blood walls are only seen at the end room, thus foreshadowing the end of Martin Fitch.
- In the room where Dr. Fitch is seen mutilating himself before the boss fight, messages written in blood can be seen in the wall (presumably written by Fitch), such as: "I'm sorry, I miss you my only daughter, please come back, I want to die, Daddy misses you, where did I go wrong?" etc.