The title follows the character's name in the following format:
- <name> the Insane
This title has been confirmed to be acquire-able as of Cataclysm by a blue post:
Yes, you can still earn the Insane In The Membrane achievement, which grants the title.
Cataclysm made some aspects of it a bit easier, and some even more insane than before. Ravenholdt reputation in particular, if you didn't work on it prior to 4.0, is simply punishing.
Have fun out there!
Unlike achievements, feats of strength normally do not track partial completion. The achievement is an exception, but prior to the tracking of exalted reputations for this achievement was buggy and the play may not have been credited correctly.
This was often considered one of the hardest titles to acquire (although Scarab Lord is more rare.)
Complete Guide by Fannin/Cogsworth
Insane in the Membrane FoS Guide - By Cogsworth of Ysera-US.
Fannin of Crushridge US had taken the time to write an extensive guide on how to do this achievement. It is recommended that you read this guide (in addition to this page) if you are serious about attempting to get "the Insane" title. At some point Fannin appears to have changed names to Cogsworth and moved to Ysera-US server.
The way to Insanity
The way to Insanity (getting the title) is long, requires a lot of farming and a lot of things to do. If you plan to become the Insane, bring your friends, your patience and your best farming skills and get ready. Listing all things that must be done from the easiest up to the hardest one should begin with the bloody pirates.
Getting honored with the Buccaneers is maybe the easiest thing. Just get in Booty Bay and start killing NPCs and Guards. Watch out for those who shoot you, because you can end up dead in the middle of the ocean. Assuming that you start at around 0/3000 Hostile with the pirates, you'll need to kill around 500 guards to become honored, while each guard gives you 25 reputation with Bloodsail Buccaneers and reduces your reputation with Booty Bay by 125. And since that is linked with the cartel you'll lose reputation with the other 3 cities as well. You'll probably end up at 0/36000 hated with Booty Bay and somewhere in low hated with the other cities, by the time you'll hit honored with the pirates.
Things are getting tough, you now have to increase your Steamwheedle Cartel reputation to exalted without ruining your Bloodsail Buccaneers reputation. (at the moment - November 19th - you don't need to have honored with Bloodsail Buccaneers and exalted with Steamwheedle Cartel at the same time, confirmed by a GM)
You can achieve that either by killing pirates, but most of them do not give you reputation in exalted, and it would require an extreme amount of kills to achieve so (Assuming that you require 84000 reputation to hit exalted, you'd have to farm around 16800 mobs, and then again, you'd have to farm more, since some mobs don't give reputation with certain cities).
As of patch 4.0.1 the pirates outside of Gadgetzan and Ratchet will no longer give reputation with their respective cities. Also in Cataclysm these pirates will be removed due to the shattering.
**As of patch 4.0.3, once Cataclysm became active, Dire Maul is no longer a viable way to gain Steamweedle Rep. The Quest Free Knot! is no longer available and the quest Gordok Ogre Suit no longer provides a rep increase.** Also, since Shen'dralar reputation is no longer required for The Insane, there is no point being in Dire Maul at all.
**For posterity's sake only:** "One way to do so is to run Dire Maul which of course is needed for Shen'dralar reputation too. Begin running Dire Maul and complete  and  . Assuming the best of luck to you with dropping (the item required for Free Knot!) each time, you'll require around 200 runs in Dire Maul to become exalted with the cartel. This should take at least 60 hours to complete, due to Blizzard's 'Five Instances per Hour' rule. Be sure not to reset Dire Maul until at least 12 minutes have passed, or you may find yourself locked out for a while." **Note: After 4.0.3 this is no longer available as a choice.**
The best way to gain reputation now is through killing Venture Trading Company mobs, preferably in Grizzly Hills. Each kill should yield either 2 or 3 reputation with Everlook and Gadgetzan, and 5 for Booty Bay. It will take 33,600 kills to get Exalted with each of the goblin towns, but if you manage to get 10 kills per minute, this grind will only take you 56 hours to complete.
Please Note that the Shen'dralar faction will be removed as a requirement for after The Shattering takes places in patch 4.0.3a, as it will be no longer possible to gain reputation with this faction. Players who already have the faction at Exalted will eventually receive a separate Feat of Strength. 
Assuming that you are exalted with the Cartel, and you have ran Dire Maul those 200 times, you'll probably have acquired around 84 librams required to get exalted with Shen'dralar. If not, run Dire Maul, or check the Auction House for those. You'll need 84 (any combination) of , or . Along with these you'll have to bring with you 84 , a bunch of and some other level 60 items such as , and , which can be acquired from bosses in Scholomance, from abominations in Stratholme and in Blood of Heroes, in Eastern Plaguelands, Western Plaguelands and Tirisfal Glades respectively.
Shen'dralar historical notes & tips
Consider forming a guild on one of your alts and purchase a Guild Bank Tab for 100 gold. When you acquire librams you can mail them to your alt and store as many unique librams as you wish. Then when you want to start turning them in you can mail them to your Insane character and acquire the use of a MOLL-E.
Each libram is Unique. Meaning that after you loot one you won't be able to loot the same one. Having one in your inventory or in your bank, makes you unable to even see if there is another libram like this. This is a major problem both while farming for librams and while turning them back. The best thing to do is to stop, if you get a libram, send it with mail to one of your alts, and go back into the instance, apart from that, if you have the materials required make a quick stop to the library room of the instance, and do the quest, to get 500 reputation, and to be able to loot the same Libram once again.
In case you want to give all the librams at the same time, consider bringing a friend that can spawn a MOLL-E. This will make your life far easier. An Argent Squire or An Argent Gruntling can also be helpful.
Not true after Cataclysm.
DO NOT DELETE/USE THE ARCANUMS! They can be used to increase your Zandalar tribe reputation, by doing:  ,  and 
Things are getting tougher with Ravenholdt. Those rogues are sworn enemies of the Syndicate. And your first step is to start farming Syndicate Mobs. Move to Hillsbrad Foothills, and start farming those mobs. By getting 5 reputation of each mob you are required to kill 4200 of those, to get to 11999/12000 Honored, which will take roughly 3.5 hours if done correctly. After that you will have to do the repeatable quest  in which you have to turn in 5 for 75 reputation. You'll need 1400 of those boxes to hit exalted with the rogues. The main problem, is that those 1400 Junkboxes, have to be pickpocketed from high level Azeroth Mobs (Old World to be exact). Only a rogue can do that, so, either get someone else to do it for you , or start leveling a rogue (the second option is preferred since you are the Insane, not the others around you).
- See also Farming Heavy Junkboxes.
Ravenholdt notes & tips
- While farming Syndicate mobs, you'll notice that they respawn fast. Just make a good rotation around Durnholde Keep. By personal experience I can say that it is possible to farm 100 reputation per minute (20 mobs), 6000 reputation per hour.
If you choose to farm inside the keep instead, you will roughly be able to get 3000 reputation per hour, making the farm less efficient.
- If you consider leveling up your 60 level rogue, get Herbalism and Inscription as your professions. Farm every low level herb you can, because they are needed for the last and most difficult part of the achievement.
- If you want someone else to farm them for you a payment of 10 gold per box works on some servers.
The most difficult of all to get to exalted. Before starting turning in decks, consider doing the Darkmoon Faire quests. A good list can be found here. After hitting the max you can with quests, the cheapest solution to hit exalted is to create decks with Inscription. Each gives 25 reputation, which means that you have to farm tons and tons of herbs (or buy them), mill them, create inks, create cards and combine them to decks.
The bad news are that the cards and the decks are not stackable, so at a point you'll have to start storing them somewhere else (your mailbox for example).
The even worse news are that you'll have to turn in 1680 decks, from 0/3000 neutral, to reach exalted, which translates to at least 5040 , since as the item says, you'll get a Random card of the Deck (and we chose rogues, since they can be made from low-level inks and thus low-level herbs which are cheaper, and the deck only requires 3 cards).
- Patch 4.0.3a (2010-11-23): Shen'dralar removed as a requirement.
- / Patch 3.0.2 (14-Oct-2008): Added.
- ^ Kaivax 2011-07-11. #13 - Can one still aquire the Insane title?. Official General Discussion forum (US).
- ^ Cogsworth of Ysera-US. Insane in the Membrane. Retrieved on 2011-11-11.
- ^ Bloodsail Buccaneers reputation list
- ^ Southsea Freebooters reputation
- ^ Southsea Pirates reputation
- ^ Battle.net WoW Cataclysm Blog - Insane in the Membrane after The Shattering