The Pain Elemental appears in Doom 64 with an altered design. It is colored dark pink (like the original cacodemon while the Doom 64 cacodemon was colored beige brown and had two arms), has a green eye and in place of its arms are two mouths so it can now spawn two lost souls at the same time. Its back has a large horse-like black mane. It gives off a low sinister laugh when it has sighted the player. Unlike other versions of the game, standing at point-blank range to prevent it from spawning lost souls is not a viable option; each lost soul that fails to materialize will cause a significant amount of damage, comparable to an exploding barrel - getting hit by both is roughly the same as being hit by a rocket (this makes the Pain Elemental very effective at monster infighting as well). This extends to the lost souls its spawns during its death sequence as well.