Lore:

She keeps seeing those things on further episode when her friends died by Rinny, however, she was not Rinny, it was The Narrator who uses Rinny as a vessel to the screen on their victims to kill and torture some Malino's and make Elma suffer due to these episodes all over again for 1000 time.

Elma didn't sleep and happy sometimes, until she's not fine due to panicking.

Whenever she was sick or it, she discovered a new task due to stopping her, torture, is the key to led her sadistic mind of flicker of peace, and made her decision.

Her crown, whoever, is no more.

The PTSD strikes Elma led to Narrator's loop of suffering of her world.

So she kepts killing those Malino's in the town residents, including sadistic one's, leading Pretty Blood company was in despair to her encounter that they will stop The Narrator for stealing her kill.

She wants something more than that.

That they will killing her friends, and even Carl mourning to her death, making Elma cried to her sorrow and going insane.

And after killing a lot more, she feels stronger, more sadistic than ever.

She will begin to turn 21 after that, till she feels regret what happened.

The Narrator keeps mocking her.

And Carl was a phantom to her support to feel better when she needs her.

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The Societies (Elma -> Murder!Sans)

The Narrator (Rinny -> The Player)

The Guider (Carl -> Phantom!Papyrus)